FHIR Implementation Guide for HCX
0.7.0 - CI Build

FHIR Implementation Guide for HCX - Local Development build (v0.7.0). See the Directory of published versions

Resource Profile: HCX Coverage

Defining URL:https://swasth-digital-health-foundation.github.io/standards/v0.7/StructureDefinition-Coverage.html
Version:0.7.0
Name:Coverage
Status:Draft as of 2019-11-01 09:29:23+1100 (Standards Status: Trial Use)
Definition:

Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.

Publisher:HCX Open Community
Committee:Financial Management
Maturity:0
Source Resource:XML / JSON / Turtle

The official URL for this profile is:

https://swasth-digital-health-foundation.github.io/standards/v0.7/StructureDefinition-Coverage.html

Formal Views of Profile Content

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

This structure is derived from Coverage

Summary

Mandatory: 1 element

Maturity: 0

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... identifier Σ1..*IdentifierBusiness Identifier for the coverage

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ1..*IdentifierBusiness Identifier for the coverage
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ0..1CodeableConceptCoverage 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 Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId Σ0..1stringID assigned to the subscriber
... beneficiary Σ1..1Reference(Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period Σ0..1PeriodCoverage start and end dates
... payor Σ1..*Reference(Organization | Patient | RelatedPerson)Issuer of the policy
... class 0..*BackboneElementAdditional coverage classifications
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

.... value Σ1..1stringValue associated with the type
.... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

This structure is derived from Coverage

Summary

Mandatory: 1 element

Maturity: 0

Differential View

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... identifier Σ1..*IdentifierBusiness Identifier for the coverage

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ1..*IdentifierBusiness Identifier for the coverage
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ0..1CodeableConceptCoverage 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 Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId Σ0..1stringID assigned to the subscriber
... beneficiary Σ1..1Reference(Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period Σ0..1PeriodCoverage start and end dates
... payor Σ1..*Reference(Organization | Patient | RelatedPerson)Issuer of the policy
... class 0..*BackboneElementAdditional coverage classifications
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

.... value Σ1..1stringValue associated with the type
.... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet
Coverage.languagepreferredCommonLanguages
Max Binding: AllLanguages
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

Constraints

IdGradePathDetailsRequirements
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-1errorCoverage.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.policyHolderAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.subscriberAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.subscriberIdAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.beneficiaryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.dependentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.relationshipAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.periodAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.payorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.classAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.class.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.class.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.class.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.class.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.class.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.class.valueAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.class.nameAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.orderAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.networkAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.costToBeneficiaryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.costToBeneficiary.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.costToBeneficiary.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.costToBeneficiary.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.costToBeneficiary.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.costToBeneficiary.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.costToBeneficiary.value[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.costToBeneficiary.exceptionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.costToBeneficiary.exception.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.costToBeneficiary.exception.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.costToBeneficiary.exception.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.costToBeneficiary.exception.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.costToBeneficiary.exception.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.costToBeneficiary.exception.periodAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.subrogationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.contractAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())