CARIN Consumer Realtime Pharmacy Benefit Check - Local Development build (v0.1.00-DRAFT). See the Directory of published versions
SD.6 StructureDefinition-carin-rtpbc-Coverage
title: StructureDefinition-carin-rtpbc-Coverage-intro layout: default active: StructureDefinition-carin-rtpbc-Coverage-intro —
This profile constrains the Coverage resource for carrying the pharmacy benefit information required in the consumer real-time pharmacy benefit check process
SD.6.1 Formal Views of Profile Content
Description of Profiles, Differentials, and Snapshots.
The official URL for this profile is: http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-request-coverage-identifiers
Published on Tue Oct 15 00:00:00 CDT 2019 as a draft by CARIN Alliance.
This profile builds on Coverage
Summary
Mandatory: 0 element (5 nested mandatory elements)
Must-Support: 9 elements
Slices
This structure defines the following Slices:
- The element Coverage.class is sliced based on the value of value:type (Closed)
Differential View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Coverage | 0..* | |||
 subscriberId | S | 0..1 | string | Health Plan Cardholder ID |
| payor | S | 1..1 | Reference(Organization | Patient | RelatedPerson) | Payer ID or Ref (TBD) |
  identifier | S | 0..1 | Identifier | Payer ID |
 system | 0..1 | uri | Payer ID System (TBD) | |
| value | S | 1..1 | string | Payer ID Value |
 class | S | 0..4 | (Slice Definition) | Pharmacy coverage identifiers Slice: Unordered, Closed by value:type |
  class:bin | S | 0..1 | BackboneElement | IIN (BIN) number |
  type | 1..1 | CodeableConcept | Required Pattern: At least the following | |
 coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin | |
| class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN) |
| type | 1..1 | CodeableConcept | Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn | |
| class:group-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID |
| type | 1..1 | CodeableConcept | Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |
 class:pbm-member-id | S | 0..1 | BackboneElement | PBM Member ID |
| type | 1..1 | CodeableConcept | Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | I | 0..* | Insurance or medical plan or a payment agreement | |
 id | Σ | 0..1 | string | Logical id of this artifact |
 meta | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
 contained | 0..* | Resource | Contained, inline Resources | |
 extension | I | 0..* | Extension | Additional content defined by implementations |
 modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ΣI | 0..* | Identifier | Business Identifier for the coverage |
| status | ?!ΣI | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required) |
| type | ΣI | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred) |
 policyHolder | ΣI | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy |
| subscriber | ΣI | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy |
| subscriberId | SΣI | 0..1 | string | Health Plan Cardholder ID |
| beneficiary | ΣI | 1..1 | Reference(Patient) | Plan beneficiary |
| dependent | ΣI | 0..1 | string | Dependent number |
| relationship | I | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) |
| period | ΣI | 0..1 | Period | Coverage start and end dates |
| payor | SΣI | 1..1 | Reference(Organization | Patient | RelatedPerson) | Payer ID or Ref (TBD) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| reference | ΣI | 0..1 | string | Literal reference, Relative, internal or absolute URL |
| type | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | SΣI | 0..1 | Identifier | Payer ID |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | ΣI | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | ΣI | 0..1 | uri | Payer ID System (TBD) Example General: http://www.acme.com/identifiers/patient |
| value | SΣI | 1..1 | string | Payer ID Value Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| class | SI | 0..4 | (Slice Definition) | Pharmacy coverage identifiers Slice: Unordered, Closed by value:type |
| class:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) |
| value | ΣI | 1..1 | string | Value associated with the type |
| name | ΣI | 0..1 | string | Human readable description of the type and value |
| class:bin | SI | 0..1 | BackboneElement | IIN (BIN) number |
 id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) 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: rxbin | |
| 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 | ΣI | 1..1 | string | Value associated with the type |
| name | ΣI | 0..1 | string | Human readable description of the type and value |
| class:pcn | SI | 0..1 | BackboneElement | Processor Control Number (PCN) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) 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: rxpcn | |
| 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 | ΣI | 1..1 | string | Value associated with the type |
| name | ΣI | 0..1 | string | Human readable description of the type and value |
| class:group-id | SI | 0..1 | BackboneElement | Pharmacy Benefit Group ID |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) 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 | ΣI | 1..1 | string | Value associated with the type |
| name | ΣI | 0..1 | string | Human readable description of the type and value |
| class:pbm-member-id | SI | 0..1 | BackboneElement | PBM Member ID |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) 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: rxid | |
| 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 | ΣI | 1..1 | string | Value associated with the type |
| name | ΣI | 0..1 | string | Human readable description of the type and value |
| order | ΣI | 0..1 | positiveInt | Relative order of the coverage |
| network | ΣI | 0..1 | string | Insurer network |
| costToBeneficiary | I | 0..* | BackboneElement | Patient payments for services/products |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible) |
 value[x] | ΣI | 1..1 | The amount or percentage due from the beneficiary | |
| valueQuantity | Quantity(SimpleQuantity) | |||
| valueMoney | Money | |||
| exception | I | 0..* | BackboneElement | Exceptions for patient payments |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Exception category Binding: ExampleCoverageFinancialExceptionCodes (example) |
| period | ΣI | 0..1 | Period | The effective period of the exception |
| subrogation | I | 0..1 | boolean | Reimbursement to insurer |
| contract | I | 0..* | Reference(Contract) | Contract details |
| Documentation for this format | ||||
Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron
