AU eRequesting Implementation Guide
1.0.0-ballot - Ballot Australia flag

AU eRequesting Implementation Guide, published by HL7 Australia. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7au/au-fhir-erequesting/ and changes regularly. See the Directory of published versions

Resource Profile: AU eRequesting Coverage

Official URL: http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-coverage Version: 1.0.0-ballot
Standards status: Draft Maturity Level: 1 Computable Name: AUeRequestingCoverage

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License. HL7 Australia© 2024+; Licensed Under Creative Commons No Rights Reserved.

This profile sets minimum expectations for a Coverage resource that is used to record, search, and fetch information about insurance or medical plan or a payment agreement for a patient. It is based on the AU Base Coverage and identifies the additional constraints, extensions, vocabularies and value sets that SHALL be present in the Coverage when conforming to this profile.

Usages:

You can also check for usages in the FHIR IG Statistics

Changes since version 0.1.0-ballot:

  • New Content

    • Formal Views of Profile Content

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

    This structure is derived from AUBaseCoverage

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Coverage AUBaseCoverage
    ... type SO 1..1 CodeableConcept Coverage category such as medical or accident
    Binding: Coverage Type and Self-Pay Codes - AU Extended (preferred)
    Additional BindingsPurpose
    AU eRequesting Coverage Type and Self-Pay Codes Min Binding
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Coverage.typepreferredCoverageTypeandSelfPayCodesAUExtended
    http://terminology.hl7.org.au/ValueSet/au-coverage-type-extended
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Coverage 0..* AUBaseCoverage 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 ?!Σ 1..1 code active | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
    ... type SOΣ 1..1 CodeableConcept Coverage category such as medical or accident
    Binding: Coverage Type and Self-Pay Codes - AU Extended (preferred)
    Additional BindingsPurpose
    AU eRequesting Coverage Type and Self-Pay Codes Min Binding
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... beneficiary Σ 1..1 Reference(Patient) Plan beneficiary
    ... payor Σ 1..* Reference(Organization | Patient | RelatedPerson) 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
    Coverage.typepreferredCoverageTypeandSelfPayCodesAUExtended
    http://terminology.hl7.org.au/ValueSet/au-coverage-type-extended

    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()
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Coverage 0..* AUBaseCoverage 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.
    Additional BindingsPurpose
    AllLanguages Max Binding
    ... 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, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber, AUPensionerConcessionCardNumber, AUCwlthSeniorsHealthCardNumber, AUHealthCareCardNumber 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 SOΣ 1..1 CodeableConcept Coverage category such as medical or accident
    Binding: Coverage Type and Self-Pay Codes - AU Extended (preferred)
    Additional BindingsPurpose
    AU eRequesting Coverage Type and Self-Pay Codes Min Binding
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... policyHolder Σ 0..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
    ... subscriber Σ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
    ... subscriberId Σ 0..1 string ID assigned to the subscriber
    ... beneficiary Σ 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 Σ 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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    Coverage.languagepreferredCommonLanguages
    http://hl7.org/fhir/ValueSet/languages
    From the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    Coverage.statusrequiredFinancialResourceStatusCodes
    http://hl7.org/fhir/ValueSet/fm-status|4.0.1
    From the FHIR Standard
    Coverage.typepreferredCoverageTypeandSelfPayCodesAUExtended
    http://terminology.hl7.org.au/ValueSet/au-coverage-type-extended
    Coverage.relationshipextensibleSubscriberRelationshipCodes
    http://hl7.org/fhir/ValueSet/subscriber-relationship
    From the FHIR Standard
    Coverage.class.typeextensibleCoverageClassCodes
    http://hl7.org/fhir/ValueSet/coverage-class
    From the FHIR Standard
    Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
    http://hl7.org/fhir/ValueSet/coverage-copay-type
    From the FHIR Standard
    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 AUBaseCoverage

    Summary

    Mandatory: 1 element
    Must-Support: 1 element

    Maturity: 1

    Differential View

    This structure is derived from AUBaseCoverage

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Coverage AUBaseCoverage
    ... type SO 1..1 CodeableConcept Coverage category such as medical or accident
    Binding: Coverage Type and Self-Pay Codes - AU Extended (preferred)
    Additional BindingsPurpose
    AU eRequesting Coverage Type and Self-Pay Codes Min Binding
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Coverage.typepreferredCoverageTypeandSelfPayCodesAUExtended
    http://terminology.hl7.org.au/ValueSet/au-coverage-type-extended

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Coverage 0..* AUBaseCoverage 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 ?!Σ 1..1 code active | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
    ... type SOΣ 1..1 CodeableConcept Coverage category such as medical or accident
    Binding: Coverage Type and Self-Pay Codes - AU Extended (preferred)
    Additional BindingsPurpose
    AU eRequesting Coverage Type and Self-Pay Codes Min Binding
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... beneficiary Σ 1..1 Reference(Patient) Plan beneficiary
    ... payor Σ 1..* Reference(Organization | Patient | RelatedPerson) 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
    Coverage.typepreferredCoverageTypeandSelfPayCodesAUExtended
    http://terminology.hl7.org.au/ValueSet/au-coverage-type-extended

    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()

    Snapshot View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Coverage 0..* AUBaseCoverage 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.
    Additional BindingsPurpose
    AllLanguages Max Binding
    ... 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, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber, AUPensionerConcessionCardNumber, AUCwlthSeniorsHealthCardNumber, AUHealthCareCardNumber 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 SOΣ 1..1 CodeableConcept Coverage category such as medical or accident
    Binding: Coverage Type and Self-Pay Codes - AU Extended (preferred)
    Additional BindingsPurpose
    AU eRequesting Coverage Type and Self-Pay Codes Min Binding
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... policyHolder Σ 0..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
    ... subscriber Σ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
    ... subscriberId Σ 0..1 string ID assigned to the subscriber
    ... beneficiary Σ 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 Σ 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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    Coverage.languagepreferredCommonLanguages
    http://hl7.org/fhir/ValueSet/languages
    From the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    Coverage.statusrequiredFinancialResourceStatusCodes
    http://hl7.org/fhir/ValueSet/fm-status|4.0.1
    From the FHIR Standard
    Coverage.typepreferredCoverageTypeandSelfPayCodesAUExtended
    http://terminology.hl7.org.au/ValueSet/au-coverage-type-extended
    Coverage.relationshipextensibleSubscriberRelationshipCodes
    http://hl7.org/fhir/ValueSet/subscriber-relationship
    From the FHIR Standard
    Coverage.class.typeextensibleCoverageClassCodes
    http://hl7.org/fhir/ValueSet/coverage-class
    From the FHIR Standard
    Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
    http://hl7.org/fhir/ValueSet/coverage-copay-type
    From the FHIR Standard
    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 AUBaseCoverage

    Summary

    Mandatory: 1 element
    Must-Support: 1 element

    Maturity: 1

     

    Other representations of profile: CSV, Excel, Schematron

    Notes:

    Below is an overview of the mandatory and optional search parameters and combined search parameters. See the AU eRequesting CapabilityStatements for a complete list of supported RESTful interactions for this IG.

    FHIR search operations are described here and the syntax used to describe AU eRequesting interactions is defined here.

    Any search parameter defined in FHIR may be ‘allowed’ by the system unless explicitly marked as “SHALL NOT”.

    Parameter(s) Server Conformance Placer Conformance Filler Conformance Patient Conformance Type(s) Requirements (when used alone or in combination)
    _id SHALL MAY MAY MAY token

    Search Parameters:

    The following search parameters and search parameter combinations are supported. Conformance obligations are detailed in the table above.

    1. _id search parameter

      GET [base]/Coverage?_id=[id]

      Example:

      1. GET [base]/Coverage?_id=10045786

    Implementation Notes: Fetches a bundle with the requested Coverage, instead of just the resource itself, and allows for the inclusion of additional search parameters such as _include, _revinclude, or _lastUpdated (how to search by id of the resource)