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/nhdr-fhir-ig-review-project-2/ 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:

- Refer to this Profile: PH Claim and PH EnrollmentRequest

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.

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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.
policyHolder | Σ | 0..1 | Reference(PH Patient | PH RelatedPerson | PH Organization) | Owner of the policy
beneficiary | Σ | 1..1 | Reference(PH Patient) | Plan beneficiary
payor | Σ | 1..* | Reference(PH Organization | PH Patient) | Issuer of the policy
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
Coverage.class.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()`

This structure is derived from Coverage

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
meta |  |  |  |
Slices for extension |  |  |  | Content/Rules for all slices
extension:hfRecordedDate |  | 0..1 | dateTime | The recorded date indicating when the record was uploaded by the health facility. URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFRecordedDate
extension:hfLastUpdated |  | 0..* | dateTime | The date indicating when the record was last updated by the health facility. URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFLastUpdated
lastUpdated |  | 0..1 | instant | When the resource was uploaded to the NHDR.
implicitRules |  | 0..0 |  | A set of rules under which this content was created
language |  | 0..0 |  | Language of the resource content
text |  | 0..0 |  | Text summary of the resource, for human interpretation
contained |  | 0..0 |  | Contained, inline Resources
extension |  | 0..0 |  | Extension
modifierExtension |  | 0..0 |  | Extension
policyHolder |  | 0..1 | Reference(PH Patient | PH RelatedPerson | PH Organization) | Owner of the policy
subscriber |  | 0..0 |  | Subscriber to the policy
subscriberId |  | 0..0 |  | ID assigned to the subscriber
beneficiary |  | 1..1 | Reference(PH Patient) | Plan beneficiary
dependent |  | 0..0 |  | Dependent number
relationship |  | 0..0 |  | Beneficiary relationship to the subscriber
period |  | 0..0 |  | Coverage start and end dates
payor |  | 1..* | Reference(PH Organization | PH Patient) | Issuer of the policy
class |  | 0..0 |  | Additional coverage classifications
order |  | 0..0 |  | Relative order of the coverage
network |  | 0..0 |  | Insurer network
costToBeneficiary |  |  |  |
id |  | 0..0 |  | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension
modifierExtension |  | 0..0 |  | Extension
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 |  | Exceptions for patient payments
subrogation |  | 0..0 |  | Reimbursement to insurer
contract |  | 0..0 |  | Contract details
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Coverage.costToBeneficiary.​type | Base | required | Coverage Copay Type | 📦0.1.0 | This IG

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
extension:hfRecordedDate |  | 0..1 | dateTime | The recorded date indicating when the record was uploaded by the health facility. URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFRecordedDate
extension:hfLastUpdated |  | 0..* | dateTime | The date indicating when the record was last updated by the health facility. URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFLastUpdated
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource was uploaded to the NHDR.
source | Σ | 0..1 | uri | Identifies where the resource comes from
profile | Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
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.
policyHolder | Σ | 0..1 | Reference(PH Patient | PH RelatedPerson | PH Organization) | Owner of the policy
beneficiary | Σ | 1..1 | Reference(PH 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 | Status | Usage | ValueSet | Version | Source
Coverage.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std.
Coverage.meta.tag | Base | example | Common Tags | 📍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.class.type | Base | extensible | Coverage Class Codes | 📍4.0.1 | FHIR Std.
Coverage.costToBeneficiary.​type | Base | required | Coverage Copay Type | 📦0.1.0 | This IG
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()`

This structure is derived from Coverage

Summary

Prohibited: 20 elements

Structures

This structure refers to these other structures:

- PH Patient (https://nhdr.gov.ph/fhir/StructureDefinition/PH-Patient)
- PH RelatedPerson (https://nhdr.gov.ph/fhir/StructureDefinition/PH-RelatedPerson)
- PH Organization (https://nhdr.gov.ph/fhir/StructureDefinition/PH-Organization)

Extensions

This structure refers to these extensions:

- https://nhdr.gov.ph/fhir/StructureDefinition/HFRecordedDate
- https://nhdr.gov.ph/fhir/StructureDefinition/HFLastUpdated

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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.
policyHolder | Σ | 0..1 | Reference(PH Patient | PH RelatedPerson | PH Organization) | Owner of the policy
beneficiary | Σ | 1..1 | Reference(PH Patient) | Plan beneficiary
payor | Σ | 1..* | Reference(PH Organization | PH Patient) | Issuer of the policy
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
Coverage.class.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()`

Differential View

This structure is derived from Coverage

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
meta |  |  |  |
Slices for extension |  |  |  | Content/Rules for all slices
extension:hfRecordedDate |  | 0..1 | dateTime | The recorded date indicating when the record was uploaded by the health facility. URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFRecordedDate
extension:hfLastUpdated |  | 0..* | dateTime | The date indicating when the record was last updated by the health facility. URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFLastUpdated
lastUpdated |  | 0..1 | instant | When the resource was uploaded to the NHDR.
implicitRules |  | 0..0 |  | A set of rules under which this content was created
language |  | 0..0 |  | Language of the resource content
text |  | 0..0 |  | Text summary of the resource, for human interpretation
contained |  | 0..0 |  | Contained, inline Resources
extension |  | 0..0 |  | Extension
modifierExtension |  | 0..0 |  | Extension
policyHolder |  | 0..1 | Reference(PH Patient | PH RelatedPerson | PH Organization) | Owner of the policy
subscriber |  | 0..0 |  | Subscriber to the policy
subscriberId |  | 0..0 |  | ID assigned to the subscriber
beneficiary |  | 1..1 | Reference(PH Patient) | Plan beneficiary
dependent |  | 0..0 |  | Dependent number
relationship |  | 0..0 |  | Beneficiary relationship to the subscriber
period |  | 0..0 |  | Coverage start and end dates
payor |  | 1..* | Reference(PH Organization | PH Patient) | Issuer of the policy
class |  | 0..0 |  | Additional coverage classifications
order |  | 0..0 |  | Relative order of the coverage
network |  | 0..0 |  | Insurer network
costToBeneficiary |  |  |  |
id |  | 0..0 |  | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension
modifierExtension |  | 0..0 |  | Extension
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 |  | Exceptions for patient payments
subrogation |  | 0..0 |  | Reimbursement to insurer
contract |  | 0..0 |  | Contract details
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Coverage.costToBeneficiary.​type | Base | required | Coverage Copay Type | 📦0.1.0 | This IG

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
extension:hfRecordedDate |  | 0..1 | dateTime | The recorded date indicating when the record was uploaded by the health facility. URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFRecordedDate
extension:hfLastUpdated |  | 0..* | dateTime | The date indicating when the record was last updated by the health facility. URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFLastUpdated
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource was uploaded to the NHDR.
source | Σ | 0..1 | uri | Identifies where the resource comes from
profile | Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
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.
policyHolder | Σ | 0..1 | Reference(PH Patient | PH RelatedPerson | PH Organization) | Owner of the policy
beneficiary | Σ | 1..1 | Reference(PH 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 | Status | Usage | ValueSet | Version | Source
Coverage.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std.
Coverage.meta.tag | Base | example | Common Tags | 📍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.class.type | Base | extensible | Coverage Class Codes | 📍4.0.1 | FHIR Std.
Coverage.costToBeneficiary.​type | Base | required | Coverage Copay Type | 📦0.1.0 | This IG
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()`

This structure is derived from Coverage

Summary

Prohibited: 20 elements

Structures

This structure refers to these other structures:

- PH Patient (https://nhdr.gov.ph/fhir/StructureDefinition/PH-Patient)
- PH RelatedPerson (https://nhdr.gov.ph/fhir/StructureDefinition/PH-RelatedPerson)
- PH Organization (https://nhdr.gov.ph/fhir/StructureDefinition/PH-Organization)

Extensions

This structure refers to these extensions:

- https://nhdr.gov.ph/fhir/StructureDefinition/HFRecordedDate
- https://nhdr.gov.ph/fhir/StructureDefinition/HFLastUpdated

Other representations of profile: CSV, Excel, Schematron