Coverage
Full Profile Definition: | Profile: Insurance Coverage |
Resource Content:
Differential
Coverage | I | Coverage | There are no (further) constraints on this element Element idCoverage Insurance or medical plan or a payment agreement DefinitionFinancial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment. The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.
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id | Σ | 1..1 | string | There are no (further) constraints on this element Element idCoverage.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
meta | Σ | 1..1 | Element: Meta | Element idCoverage.meta Metadata about a resource DefinitionThe metadata about a resource. This is content in the resource that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idCoverage.implicitRules A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idCoverage.language Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
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text | 0..1 | Narrative | There are no (further) constraints on this element Element idCoverage.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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contained | 0..* | Resource | There are no (further) constraints on this element Element idCoverage.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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identifier | Σ | 0..* | Element: Identifier | Element idCoverage.identifier a value to identify the resource by DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. Allows coverages to be distinguished and referenced. The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant. Unordered, Open, by slice by types Constraints
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id | S | 1..1 | string | There are no (further) constraints on this element Element idCoverage.identifier.id Unique id for the element DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. set case-by-case
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.identifier.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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use | S Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idCoverage.identifier.use usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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type | S Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCoverage.identifier.type Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
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id | 0..1 | string | There are no (further) constraints on this element Element idCoverage.identifier.type.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.identifier.type.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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coding | Σ | 1..* | CodingBinding | There are no (further) constraints on this element Element idCoverage.identifier.type.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. https://www.hl7.org/fhir/us/bwell/bwell-vs-identifier-type (extensible) Constraints
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id | 1..1 | string | There are no (further) constraints on this element Element idCoverage.identifier.type.coding.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.identifier.type.coding.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idCoverage.identifier.type.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.identifier.type.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 1..1 | code | There are no (further) constraints on this element Element idCoverage.identifier.type.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.identifier.type.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idCoverage.identifier.type.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.identifier.type.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element idCoverage.identifier.system The system which created the identifier DefinitionValues may be an oid, uri, url, or canonical There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive, and should not end with a "/"
General http://www.acme.com/identifiers/patient Mappings
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value | S Σ | 1..1 | string | There are no (further) constraints on this element Element idCoverage.identifier.value The unique value DefinitionThe raw identifier value that represents a resource If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
General 123456 Mappings
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period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element idCoverage.identifier.period Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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assigner | Σ I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idCoverage.identifier.assigner Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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identifier-member-number | Σ | 0..* | IdentifierPattern | Element idCoverage.identifier:identifier-member-number insurance coverage's unique identifier for the individual DefinitionA unique identifier assigned to this coverage. system = source URI The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.
{ "id": "member-number", "type": { "coding": [ { "id": "member-number-type", "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "MB" } ] } }
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medicare-beneficiary-id | Σ | 0..* | IdentifierPattern | Element idCoverage.identifier:medicare-beneficiary-id Medicare Beneficiary Identifier (US) DefinitionA unique identifier assigned to this coverage. Allows coverages to be distinguished and referenced. The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.
{ "id": "mbi", "type": { "coding": [ { "id": "mbi-type", "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "MC" } ] }, "system": "http://hl7.org/fhir/sid/us-mbi" }
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status | S Σ ?! | 1..1 | codeBinding | Element idCoverage.status Indicates validity of the resource DefinitionThe status of the resource instance. Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'. record should remain active, even after coverage termination A code specifying the state of the resource instance.
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type | S Σ | 0..1 | Element: Codeable ConceptBinding | Element idCoverage.type Type of coverage represented DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. The order of application of coverages is dependent on the types of coverage. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.
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policyHolder | Σ I | 0..1 | Reference(Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idCoverage.policyHolder Owner of the policy DefinitionThe party who 'owns' the insurance policy. This provides employer information in the case of Worker's Compensation and other policies. For example: may be an individual, corporation or the subscriber's employer. Reference(Patient | RelatedPerson | Organization) Constraints
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subscriber | S Σ I | 0..1 | Reference(Profile: Patient) | Element idCoverage.subscriber Subscriber of the insurance plan policy DefinitionThe party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due. This is the party who is entitled to the benfits under the policy. this may be the same individual as the beneficiary
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subscriberId | S Σ | 0..1 | string | Element idCoverage.subscriberId The subscribing individual's unique member number DefinitionThe insurer assigned ID for the Subscriber. The insurer requires this identifier on correspondance and claims (digital and otherwise). Note that FHIR strings SHALL NOT exceed 1MB in size
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beneficiary | S Σ I | 1..1 | Reference(Profile: Patient) | Element idCoverage.beneficiary Beneficiary of the insurance plan coverage DefinitionThe party who benefits from the insurance coverage; the patient when products and/or services are provided. This is the party who receives treatment for which the costs are reimbursed under the coverage. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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dependent | S Σ | 0..1 | string | Element idCoverage.dependent Sequence number for the dependent DefinitionA unique identifier for a dependent under the coverage. Only needed if the individual is a dependent; If the individual is the subscriber, this should be omitted Periodically the member number is constructed from the subscriberId and the dependant number.
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relationship | S | 0..1 | Element: Codeable ConceptBinding | Element idCoverage.relationship Concept - reference to a terminology or just text DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. To determine relationship between the patient and the subscriber to determine coordination of benefits. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
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period | S Σ I | 1..1 | Period | Element idCoverage.period Effective date range DefinitionTime period during which the coverage is in force. A missing start date indicates the start date isn't known, a missing end date means the coverage is continuing to be in force. Some insurers require the submission of the coverage term. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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payor | S Σ I | 1..* | Reference(Profile: Insurance Company | https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-partner-organization) | Element idCoverage.payor Paying entity DefinitionThe program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements. Need to identify the issuer to target for claim processing and for coordination of benefit processing. Typically the Insurance Company Reference(Profile: Insurance Company | https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-partner-organization) Constraints
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class | S | 0..* | BackboneElement | Element idCoverage.class Additional coverage classifications DefinitionThe codes provided on the health card which identify or confirm the specific policy for the insurer. The codes provided on the health card which identify or confirm the specific policy for the insurer. For example may be used to identify a class of coverage or employer group, Policy, Plan. Unordered, Open, by Slice by type Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idCoverage.class.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.class.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.class.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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type | S Σ | 1..1 | Element: Codeable ConceptBinding | Element idCoverage.class.type Coded value to describe the class DefinitionThe policy classifications, eg. Group, Plan, Class, etc. The insurer issued label for a specific health card value. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The policy classifications, eg. Group, Plan, Class, etc.
Group type { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "group" } ] } Mappings
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value | S Σ | 1..1 | string | There are no (further) constraints on this element Element idCoverage.class.value Value associated with the type DefinitionThe alphanumeric string value associated with the insurer issued label. The insurer issued label and value are necessary to identify the specific policy. For example, the Group or Plan number.
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name | S Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.class.name Human readable description of the type and value DefinitionA short description for the class. Used to provide a meaningful description in correspondence to the patient. Note that FHIR strings SHALL NOT exceed 1MB in size
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Group | 0..* | BackboneElement | Element idCoverage.class:Group Insurance coverage group DefinitionA suite of underwriter specific classifiers. The codes provided on the health card which identify or confirm the specific policy for the insurer. For example may be used to identify a class of coverage or employer group, Policy, Plan.
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id | 1..1 | string | There are no (further) constraints on this element Element idCoverage.class:Group.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.class:Group.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.class:Group.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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type | Σ | 1..1 | CodeableConceptBindingPattern | Element idCoverage.class:Group.type Type of class such as 'group' or 'plan' DefinitionThe type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan. The insurer issued label for a specific health card value. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The policy classifications, eg. Group, Plan, Class, etc.
{ "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "group" } ] }
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value | Σ | 1..1 | string | There are no (further) constraints on this element Element idCoverage.class:Group.value Value associated with the type DefinitionThe alphanumeric string value associated with the insurer issued label. The insurer issued label and value are necessary to identify the specific policy. For example, the Group or Plan number.
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name | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.class:Group.name Human readable description of the type and value DefinitionA short description for the class. Used to provide a meaningful description in correspondence to the patient. Note that FHIR strings SHALL NOT exceed 1MB in size
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Subgroup | 0..* | BackboneElement | Element idCoverage.class:Subgroup Insurance coverage subgroup DefinitionA suite of underwriter specific classifiers. The codes provided on the health card which identify or confirm the specific policy for the insurer. For example may be used to identify a class of coverage or employer group, Policy, Plan.
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id | 1..1 | string | There are no (further) constraints on this element Element idCoverage.class:Subgroup.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.class:Subgroup.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.class:Subgroup.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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type | Σ | 1..1 | CodeableConceptBindingPattern | Element idCoverage.class:Subgroup.type Type of class such as 'group' or 'plan' DefinitionThe type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan. The insurer issued label for a specific health card value. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The policy classifications, eg. Group, Plan, Class, etc.
{ "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "subgroup" } ] }
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value | Σ | 1..1 | string | There are no (further) constraints on this element Element idCoverage.class:Subgroup.value Value associated with the type DefinitionThe alphanumeric string value associated with the insurer issued label. The insurer issued label and value are necessary to identify the specific policy. For example, the Group or Plan number.
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name | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.class:Subgroup.name Human readable description of the type and value DefinitionA short description for the class. Used to provide a meaningful description in correspondence to the patient. Note that FHIR strings SHALL NOT exceed 1MB in size
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order | Σ | 0..1 | positiveInt | There are no (further) constraints on this element Element idCoverage.order Relative order of the coverage DefinitionThe order of applicability of this coverage relative to other coverages which are currently in force. Note, there may be gaps in the numbering and this does not imply primary, secondary etc. as the specific positioning of coverages depends upon the episode of care. Used in managing the coordination of benefits. 32 bit number; for values larger than this, use decimal
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network | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.network Insurer network DefinitionThe insurer-specific identifier for the insurer-defined network of providers to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply. Used in referral for treatment and in claims processing. Note that FHIR strings SHALL NOT exceed 1MB in size
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costToBeneficiary | 0..* | BackboneElement | There are no (further) constraints on this element Element idCoverage.costToBeneficiary Patient payments for services/products Alternate namesCoPay, Deductible, Exceptions DefinitionA suite of codes indicating the cost category and associated amount which have been detailed in the policy and may have been included on the health card. Required by providers to manage financial transaction with the patient. For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.
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id | 0..1 | string | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.type Cost category DefinitionThe category of patient centric costs associated with treatment. Needed to identify the category associated with the amount for the patient. For example visit, specialist visits, emergency, inpatient care, etc. The types of services to which patient copayments are specified.
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value[x] | Σ | 1..1 | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.value[x] The amount or percentage due from the beneficiary DefinitionThe amount due from the patient for the cost category. Needed to identify the amount for the patient associated with the category. Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.
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valueQuantity | SimpleQuantity | There are no (further) constraints on this element Data type | ||
valueMoney | Money | There are no (further) constraints on this element Data type | ||
exception | 0..* | BackboneElement | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception Exceptions for patient payments DefinitionA suite of codes indicating exceptions or reductions to patient costs and their effective periods. Required by providers to manage financial transaction with the patient.
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id | 0..1 | string | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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type | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception.type Exception category DefinitionThe code for the specific exception. Needed to identify the exception associated with the amount for the patient. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The types of exceptions from the part or full value of financial obligations such as copays.
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period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception.period The effective period of the exception DefinitionThe timeframe during when the exception is in force. Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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subrogation | 0..1 | boolean | There are no (further) constraints on this element Element idCoverage.subrogation Reimbursement to insurer DefinitionWhen 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs. See definition for when to be used. Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.
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contract | I | 0..* | Reference(Contract) | There are no (further) constraints on this element Element idCoverage.contract Contract details DefinitionThe policy(s) which constitute this insurance coverage. To reference the legally binding contract between the policy holder and the insurer. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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Hybrid
Coverage | I | Coverage | There are no (further) constraints on this element Element idCoverage Insurance or medical plan or a payment agreement DefinitionFinancial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment. The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.
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id | Σ | 1..1 | string | There are no (further) constraints on this element Element idCoverage.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
meta | Σ | 1..1 | Element: Meta | Element idCoverage.meta Metadata about a resource DefinitionThe metadata about a resource. This is content in the resource that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idCoverage.implicitRules A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idCoverage.language Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
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text | 0..1 | Narrative | There are no (further) constraints on this element Element idCoverage.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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contained | 0..* | Resource | There are no (further) constraints on this element Element idCoverage.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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identifier | Σ | 0..* | Element: Identifier | Element idCoverage.identifier a value to identify the resource by DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. Allows coverages to be distinguished and referenced. The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant. Unordered, Open, by slice by types Constraints
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(All Slices) | There are no (further) constraints on this element | |||
id | S | 1..1 | string | There are no (further) constraints on this element Element idCoverage.identifier.id Unique id for the element DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. set case-by-case
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.identifier.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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use | S Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idCoverage.identifier.use usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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type | S Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCoverage.identifier.type Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
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id | 0..1 | string | There are no (further) constraints on this element Element idCoverage.identifier.type.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.identifier.type.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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coding | Σ | 1..* | CodingBinding | There are no (further) constraints on this element Element idCoverage.identifier.type.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. https://www.hl7.org/fhir/us/bwell/bwell-vs-identifier-type (extensible) Constraints
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id | 1..1 | string | There are no (further) constraints on this element Element idCoverage.identifier.type.coding.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.identifier.type.coding.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idCoverage.identifier.type.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.identifier.type.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 1..1 | code | There are no (further) constraints on this element Element idCoverage.identifier.type.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.identifier.type.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idCoverage.identifier.type.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.identifier.type.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element idCoverage.identifier.system The system which created the identifier DefinitionValues may be an oid, uri, url, or canonical There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive, and should not end with a "/"
General http://www.acme.com/identifiers/patient Mappings
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value | S Σ | 1..1 | string | There are no (further) constraints on this element Element idCoverage.identifier.value The unique value DefinitionThe raw identifier value that represents a resource If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
General 123456 Mappings
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period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element idCoverage.identifier.period Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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assigner | Σ I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idCoverage.identifier.assigner Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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identifier-member-number | Σ | 0..* | IdentifierPattern | Element idCoverage.identifier:identifier-member-number insurance coverage's unique identifier for the individual DefinitionA unique identifier assigned to this coverage. system = source URI The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.
{ "id": "member-number", "type": { "coding": [ { "id": "member-number-type", "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "MB" } ] } }
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medicare-beneficiary-id | Σ | 0..* | IdentifierPattern | Element idCoverage.identifier:medicare-beneficiary-id Medicare Beneficiary Identifier (US) DefinitionA unique identifier assigned to this coverage. Allows coverages to be distinguished and referenced. The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.
{ "id": "mbi", "type": { "coding": [ { "id": "mbi-type", "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "MC" } ] }, "system": "http://hl7.org/fhir/sid/us-mbi" }
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status | S Σ ?! | 1..1 | codeBinding | Element idCoverage.status Indicates validity of the resource DefinitionThe status of the resource instance. Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'. record should remain active, even after coverage termination A code specifying the state of the resource instance.
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type | S Σ | 0..1 | Element: Codeable ConceptBinding | Element idCoverage.type Type of coverage represented DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. The order of application of coverages is dependent on the types of coverage. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.
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policyHolder | Σ I | 0..1 | Reference(Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idCoverage.policyHolder Owner of the policy DefinitionThe party who 'owns' the insurance policy. This provides employer information in the case of Worker's Compensation and other policies. For example: may be an individual, corporation or the subscriber's employer. Reference(Patient | RelatedPerson | Organization) Constraints
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subscriber | S Σ I | 0..1 | Reference(Profile: Patient) | Element idCoverage.subscriber Subscriber of the insurance plan policy DefinitionThe party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due. This is the party who is entitled to the benfits under the policy. this may be the same individual as the beneficiary
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subscriberId | S Σ | 0..1 | string | Element idCoverage.subscriberId The subscribing individual's unique member number DefinitionThe insurer assigned ID for the Subscriber. The insurer requires this identifier on correspondance and claims (digital and otherwise). Note that FHIR strings SHALL NOT exceed 1MB in size
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beneficiary | S Σ I | 1..1 | Reference(Profile: Patient) | Element idCoverage.beneficiary Beneficiary of the insurance plan coverage DefinitionThe party who benefits from the insurance coverage; the patient when products and/or services are provided. This is the party who receives treatment for which the costs are reimbursed under the coverage. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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dependent | S Σ | 0..1 | string | Element idCoverage.dependent Sequence number for the dependent DefinitionA unique identifier for a dependent under the coverage. Only needed if the individual is a dependent; If the individual is the subscriber, this should be omitted Periodically the member number is constructed from the subscriberId and the dependant number.
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relationship | S | 0..1 | Element: Codeable ConceptBinding | Element idCoverage.relationship Concept - reference to a terminology or just text DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. To determine relationship between the patient and the subscriber to determine coordination of benefits. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
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period | S Σ I | 1..1 | Period | Element idCoverage.period Effective date range DefinitionTime period during which the coverage is in force. A missing start date indicates the start date isn't known, a missing end date means the coverage is continuing to be in force. Some insurers require the submission of the coverage term. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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payor | S Σ I | 1..* | Reference(Profile: Insurance Company | https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-partner-organization) | Element idCoverage.payor Paying entity DefinitionThe program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements. Need to identify the issuer to target for claim processing and for coordination of benefit processing. Typically the Insurance Company Reference(Profile: Insurance Company | https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-partner-organization) Constraints
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class | S | 0..* | BackboneElement | Element idCoverage.class Additional coverage classifications DefinitionThe codes provided on the health card which identify or confirm the specific policy for the insurer. The codes provided on the health card which identify or confirm the specific policy for the insurer. For example may be used to identify a class of coverage or employer group, Policy, Plan. Unordered, Open, by Slice by type Constraints
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(All Slices) | There are no (further) constraints on this element | |||
id | 0..1 | string | There are no (further) constraints on this element Element idCoverage.class.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.class.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.class.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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type | S Σ | 1..1 | Element: Codeable ConceptBinding | Element idCoverage.class.type Coded value to describe the class DefinitionThe policy classifications, eg. Group, Plan, Class, etc. The insurer issued label for a specific health card value. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The policy classifications, eg. Group, Plan, Class, etc.
Group type { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "group" } ] } Mappings
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value | S Σ | 1..1 | string | There are no (further) constraints on this element Element idCoverage.class.value Value associated with the type DefinitionThe alphanumeric string value associated with the insurer issued label. The insurer issued label and value are necessary to identify the specific policy. For example, the Group or Plan number.
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name | S Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.class.name Human readable description of the type and value DefinitionA short description for the class. Used to provide a meaningful description in correspondence to the patient. Note that FHIR strings SHALL NOT exceed 1MB in size
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Group | 0..* | BackboneElement | Element idCoverage.class:Group Insurance coverage group DefinitionA suite of underwriter specific classifiers. The codes provided on the health card which identify or confirm the specific policy for the insurer. For example may be used to identify a class of coverage or employer group, Policy, Plan.
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id | 1..1 | string | There are no (further) constraints on this element Element idCoverage.class:Group.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.class:Group.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.class:Group.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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type | Σ | 1..1 | CodeableConceptBindingPattern | Element idCoverage.class:Group.type Type of class such as 'group' or 'plan' DefinitionThe type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan. The insurer issued label for a specific health card value. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The policy classifications, eg. Group, Plan, Class, etc.
{ "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "group" } ] }
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value | Σ | 1..1 | string | There are no (further) constraints on this element Element idCoverage.class:Group.value Value associated with the type DefinitionThe alphanumeric string value associated with the insurer issued label. The insurer issued label and value are necessary to identify the specific policy. For example, the Group or Plan number.
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name | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.class:Group.name Human readable description of the type and value DefinitionA short description for the class. Used to provide a meaningful description in correspondence to the patient. Note that FHIR strings SHALL NOT exceed 1MB in size
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Subgroup | 0..* | BackboneElement | Element idCoverage.class:Subgroup Insurance coverage subgroup DefinitionA suite of underwriter specific classifiers. The codes provided on the health card which identify or confirm the specific policy for the insurer. For example may be used to identify a class of coverage or employer group, Policy, Plan.
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id | 1..1 | string | There are no (further) constraints on this element Element idCoverage.class:Subgroup.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.class:Subgroup.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.class:Subgroup.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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type | Σ | 1..1 | CodeableConceptBindingPattern | Element idCoverage.class:Subgroup.type Type of class such as 'group' or 'plan' DefinitionThe type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan. The insurer issued label for a specific health card value. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The policy classifications, eg. Group, Plan, Class, etc.
{ "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "subgroup" } ] }
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value | Σ | 1..1 | string | There are no (further) constraints on this element Element idCoverage.class:Subgroup.value Value associated with the type DefinitionThe alphanumeric string value associated with the insurer issued label. The insurer issued label and value are necessary to identify the specific policy. For example, the Group or Plan number.
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name | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.class:Subgroup.name Human readable description of the type and value DefinitionA short description for the class. Used to provide a meaningful description in correspondence to the patient. Note that FHIR strings SHALL NOT exceed 1MB in size
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order | Σ | 0..1 | positiveInt | There are no (further) constraints on this element Element idCoverage.order Relative order of the coverage DefinitionThe order of applicability of this coverage relative to other coverages which are currently in force. Note, there may be gaps in the numbering and this does not imply primary, secondary etc. as the specific positioning of coverages depends upon the episode of care. Used in managing the coordination of benefits. 32 bit number; for values larger than this, use decimal
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network | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.network Insurer network DefinitionThe insurer-specific identifier for the insurer-defined network of providers to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply. Used in referral for treatment and in claims processing. Note that FHIR strings SHALL NOT exceed 1MB in size
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costToBeneficiary | 0..* | BackboneElement | There are no (further) constraints on this element Element idCoverage.costToBeneficiary Patient payments for services/products Alternate namesCoPay, Deductible, Exceptions DefinitionA suite of codes indicating the cost category and associated amount which have been detailed in the policy and may have been included on the health card. Required by providers to manage financial transaction with the patient. For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.
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id | 0..1 | string | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.type Cost category DefinitionThe category of patient centric costs associated with treatment. Needed to identify the category associated with the amount for the patient. For example visit, specialist visits, emergency, inpatient care, etc. The types of services to which patient copayments are specified.
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value[x] | Σ | 1..1 | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.value[x] The amount or percentage due from the beneficiary DefinitionThe amount due from the patient for the cost category. Needed to identify the amount for the patient associated with the category. Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.
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valueQuantity | SimpleQuantity | There are no (further) constraints on this element Data type | ||
valueMoney | Money | There are no (further) constraints on this element Data type | ||
exception | 0..* | BackboneElement | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception Exceptions for patient payments DefinitionA suite of codes indicating exceptions or reductions to patient costs and their effective periods. Required by providers to manage financial transaction with the patient.
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id | 0..1 | string | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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type | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception.type Exception category DefinitionThe code for the specific exception. Needed to identify the exception associated with the amount for the patient. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The types of exceptions from the part or full value of financial obligations such as copays.
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period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception.period The effective period of the exception DefinitionThe timeframe during when the exception is in force. Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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subrogation | 0..1 | boolean | There are no (further) constraints on this element Element idCoverage.subrogation Reimbursement to insurer DefinitionWhen 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs. See definition for when to be used. Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.
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contract | I | 0..* | Reference(Contract) | There are no (further) constraints on this element Element idCoverage.contract Contract details DefinitionThe policy(s) which constitute this insurance coverage. To reference the legally binding contract between the policy holder and the insurer. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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Examples:
{ "resourceType": "Coverage", "id": "BEN-5555555555-202003", "meta": { "source": "https://www.wpshealth.com/membership", "profile": [ "https://fhir.icanbwell.com/4_0_0/StructureDefinition/pr-insurance-coverage" ], "security": [ { "system": "https://www.icanbwell.com/owner", "code": "bwell" }, { "system": "https://www.icanbwell.com/access", "code": "bwell" } ] }, "identifier": [ { "id": "member-identifier", "type": { "coding": [ { "id": "member-identifier-id", "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "MB" } ] }, "system": "https://www.healthplan.com", "value": "5555555555" } ], "status": "active", "type": { "coding": [ { "id": "insurance-type", "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "ACO" } ] }, "subscriber": { "reference": "Patient/BEN-5555555555" }, "beneficiary": { "reference": "Patient/BEN-5555555555" }, "period": { "start": "2020-03-01T00:00:00.000Z", "end": "2020-03-31T00:00:00.000Z" }, "payor": [ { "reference": "Organization/Health-Insurance-Co" } ], "class": [ { "id": "class-id-1", "type": { "coding": [ { "id": "class-id-group", "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "group" } ] }, "value": "12030405", "name": "This Group Name" }, { "id": "class-id-2", "type": { "coding": [ { "id": "class-id-subgroup", "system": "http://terminology.hl7.org/CodeSystem/coverage-class", "code": "subgroup" } ] }, "value": "12030406", "name": "This SubGroup Name" } ] }