NHDR Implementation Guide Release 1.0
0.1.0 - ci-build

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

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

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageIf 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-4errorCoverageIf 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-5errorCoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* Coverage Insurance or medical plan or a payment agreement
... implicitRules 0..0
... language 0..0
... text 0..0
... extension 0..0
... modifierExtension 0..0
... policyHolder 0..0
... subscriber 0..0
... subscriberId 0..0
... dependent 0..0
... relationship 0..0
... payor 1..* Reference(PH Organization | PH Patient) Issuer of the policy
... class
.... id 0..0
.... extension 0..0
.... modifierExtension 0..0
.... name 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

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Coverage.costToBeneficiary.typerequiredCoverageCopayTypeVS
https://nhdr.gov.ph/fhir/ValueSet/CoverageCoPayTypeVS
From this IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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
... period Σ 0..1 Period Coverage start and end dates
... payor Σ 1..* Reference(PH Organization | PH Patient) Issuer of the policy
... class 0..* BackboneElement Additional coverage classifications
.... 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
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From the FHIR Standard
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
http://hl7.org/fhir/ValueSet/coverage-type
From the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
From the FHIR Standard
Coverage.costToBeneficiary.typerequiredCoverageCopayTypeVS
https://nhdr.gov.ph/fhir/ValueSet/CoverageCoPayTypeVS
From this IG
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
http://hl7.org/fhir/ValueSet/coverage-financial-exception
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageIf 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-4errorCoverageIf 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-5errorCoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Coverage

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageIf 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-4errorCoverageIf 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-5errorCoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Differential View

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* Coverage Insurance or medical plan or a payment agreement
... implicitRules 0..0
... language 0..0
... text 0..0
... extension 0..0
... modifierExtension 0..0
... policyHolder 0..0
... subscriber 0..0
... subscriberId 0..0
... dependent 0..0
... relationship 0..0
... payor 1..* Reference(PH Organization | PH Patient) Issuer of the policy
... class
.... id 0..0
.... extension 0..0
.... modifierExtension 0..0
.... name 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

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Coverage.costToBeneficiary.typerequiredCoverageCopayTypeVS
https://nhdr.gov.ph/fhir/ValueSet/CoverageCoPayTypeVS
From this IG

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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
... period Σ 0..1 Period Coverage start and end dates
... payor Σ 1..* Reference(PH Organization | PH Patient) Issuer of the policy
... class 0..* BackboneElement Additional coverage classifications
.... 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
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From the FHIR Standard
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
http://hl7.org/fhir/ValueSet/coverage-type
From the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
From the FHIR Standard
Coverage.costToBeneficiary.typerequiredCoverageCopayTypeVS
https://nhdr.gov.ph/fhir/ValueSet/CoverageCoPayTypeVS
From this IG
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
http://hl7.org/fhir/ValueSet/coverage-financial-exception
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageIf 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-4errorCoverageIf 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-5errorCoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust 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