NHDR Implementation Guide Release 1.0, published by NHDR. 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/PROJ-PHILHEALTH-EA-NHDR/PhilHealth-NHDR-IG-Review/ and changes regularly. See the Directory of published versions
Resource Profile: PH Coverage
| Official URL: https://nhdr.gov.ph/fhir/StructureDefinition/PH-Coverage | Version: 0.1.0 | |||
| Standards status: Draft | Computable Name: PH_Coverage | |||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License |
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Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.
Usages:
- This Profile is not used by any profiles in this Implementation Guide
You can also check for usages in the FHIR IG Statistics
Formal Views of Profile Content
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 | |
  status |
?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
 beneficiary |
Σ | 1..1 | Reference(Patient) | Plan beneficiary |
 payor |
Σ | 1..* | Reference(PH Organization | PH Patient) | Issuer of the policy |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet | URI |
| Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1From the FHIR Standard | |
| Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class|4.0.1From the FHIR Standard |
Constraints
| 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() |
This structure is derived from Coverage
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Coverage |
0..* | Coverage | Insurance or medical plan or a payment agreement | |
 implicitRules |
0..0 | |||
| language |
0..0 | |||
| text |
0..0 | |||
| contained |
0..0 | |||
 extension |
0..0 | |||
 modifierExtension |
0..0 | |||
| policyHolder |
0..0 | |||
| subscriber |
0..0 | |||
| subscriberId |
0..0 | |||
| dependent |
0..0 | |||
| relationship |
0..0 | |||
| period |
0..0 | |||
| payor |
1..* | Reference(PH Organization | PH Patient) | Issuer of the policy | |
| class |
0..0 | |||
| order |
0..0 | |||
| network |
0..0 | |||
 costToBeneficiary |
||||
 id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| type |
0..1 | CodeableConcept | Cost category Binding: Coverage Copay Type (required) | |
 value[x] |
1..1 | Money | The amount or percentage due from the beneficiary | |
| exception |
0..0 | |||
| subrogation |
0..0 | |||
| contract |
0..0 | |||
| Documentation for this format | ||||
Terminology Bindings (Differential)
| Path | Conformance | ValueSet | URI |
| Coverage.costToBeneficiary.type | required | CoverageCopayTypeVShttps://nhdr.gov.ph/fhir/ValueSet/CoverageCoPayTypeVSFrom this IG |
| 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 |
| identifier |
Σ | 0..* | Identifier | Business Identifier for the coverage |
| 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. |
| beneficiary |
Σ | 1..1 | Reference(Patient) | Plan beneficiary |
| payor |
Σ | 1..* | Reference(PH Organization | PH Patient) | Issuer of the policy |
 costToBeneficiary |
0..* | BackboneElement | Patient payments for services/products | |
 type |
Σ | 0..1 | CodeableConcept | Cost category Binding: Coverage Copay Type (required) |
| value[x] |
Σ | 1..1 | Money | The amount or percentage due from the beneficiary |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet | URI |
| Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1From the FHIR Standard | |
| Coverage.type | preferred | CoverageTypeAndSelf-PayCodeshttp://hl7.org/fhir/ValueSet/coverage-type|4.0.1From the FHIR Standard | |
| Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class|4.0.1From the FHIR Standard | |
| Coverage.costToBeneficiary.type | required | CoverageCopayTypeVShttps://nhdr.gov.ph/fhir/ValueSet/CoverageCoPayTypeVSFrom this IG | |
| Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodeshttp://hl7.org/fhir/ValueSet/coverage-financial-exception|4.0.1From the FHIR Standard |
Constraints
| 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() |
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 | |
| status |
?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| beneficiary |
Σ | 1..1 | Reference(Patient) | Plan beneficiary |
| payor |
Σ | 1..* | Reference(PH Organization | PH Patient) | Issuer of the policy |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet | URI |
| Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1From the FHIR Standard | |
| Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class|4.0.1From the FHIR Standard |
Constraints
| 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() |
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 | |
| implicitRules |
0..0 | |||
| language |
0..0 | |||
| text |
0..0 | |||
| contained |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| policyHolder |
0..0 | |||
| subscriber |
0..0 | |||
| subscriberId |
0..0 | |||
| dependent |
0..0 | |||
| relationship |
0..0 | |||
| period |
0..0 | |||
| payor |
1..* | Reference(PH Organization | PH Patient) | Issuer of the policy | |
| class |
0..0 | |||
| order |
0..0 | |||
| network |
0..0 | |||
| costToBeneficiary |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| type |
0..1 | CodeableConcept | Cost category Binding: Coverage Copay Type (required) | |
| value[x] |
1..1 | Money | The amount or percentage due from the beneficiary | |
| exception |
0..0 | |||
| subrogation |
0..0 | |||
| contract |
0..0 | |||
| Documentation for this format | ||||
Terminology Bindings (Differential)
| Path | Conformance | ValueSet | URI |
| Coverage.costToBeneficiary.type | required | CoverageCopayTypeVShttps://nhdr.gov.ph/fhir/ValueSet/CoverageCoPayTypeVSFrom this IG |
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 |
| identifier |
Σ | 0..* | Identifier | Business Identifier for the coverage |
| 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. |
| beneficiary |
Σ | 1..1 | Reference(Patient) | Plan beneficiary |
| payor |
Σ | 1..* | Reference(PH Organization | PH Patient) | Issuer of the policy |
| costToBeneficiary |
0..* | BackboneElement | Patient payments for services/products | |
| type |
Σ | 0..1 | CodeableConcept | Cost category Binding: Coverage Copay Type (required) |
| value[x] |
Σ | 1..1 | Money | The amount or percentage due from the beneficiary |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet | URI |
| Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1From the FHIR Standard | |
| Coverage.type | preferred | CoverageTypeAndSelf-PayCodeshttp://hl7.org/fhir/ValueSet/coverage-type|4.0.1From the FHIR Standard | |
| Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class|4.0.1From the FHIR Standard | |
| Coverage.costToBeneficiary.type | required | CoverageCopayTypeVShttps://nhdr.gov.ph/fhir/ValueSet/CoverageCoPayTypeVSFrom this IG | |
| Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodeshttp://hl7.org/fhir/ValueSet/coverage-financial-exception|4.0.1From the FHIR Standard |
Constraints
| 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() |
This structure is derived from Coverage
Other representations of profile: CSV, Excel, Schematron