Implementierungsleitfaden ISiK-Basismodul

Versicherungsverhältnis sonstige Kostenträger (Coverage)

ISiKVersicherungsverhaeltnisSonstige

Dieses Profil ermöglicht die Darstellung sonstiger Versicherungsverhältnisses in ISiK Szenarien.

Motivation

ISiK unterstützt Anwendungsszenarien, in denen durch das Krankenhaus erbrachte Leistungen erfasst oder gegenüber Kostenträgern abgerechnet werden, bei denen es sich weder um gesetzliche Versicherungen noch Selbstzahlerverhältnisse handelt. In diesen Anwendungsszenarien wird das Versicherungsverhältnis verwendet, um bspw. den Versicherungsstatus oder die Rechnungsanschrift der Versicherung zu ermitteln.
In FHIR werden Versicherungsverhältnisse mit der Coverage-Ressource repräsentiert.

Kompatibilität

Das Profil ISiKVersicherungsverhaeltnisSonstige basiert auf dem Basis-Coverage-Profil der deutschen Basisprofile.

Hinweise zu Inkompatibilitäten können über die Portalseite gemeldet werden.

Bestätigungsrelevanz

Verbindlichkeit	SHALL

Metadaten

Canonical	https://gematik.de/fhir/isik/StructureDefinition/ISiKVersicherungsverhaeltnisSonstige
Status	active
Version	5.0.0-rc
Basis	http://fhir.de/StructureDefinition/coverage-de-basis

Inhalt

ISiKVersicherungsverhaeltnisSonstige (Coverage)	I		CoverageDeBasis	There are no (further) constraints on this element Element id Coverage Short description Versicherungsdaten Definition Angaben zur Versicherung oder zur Kostenübernahme durch den Patienten selbst oder durch Dritte. Comments The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers. Data type CoverageDeBasis Constraints dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource `contained.where((('#'+id in (%resource.descendants().reference \| %resource.descendants().as(canonical) \| %resource.descendants().as(uri) \| %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()` dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()` dom-5: If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` dom-6: A resource should have narrative for robust management text.`div`.exists() Mappings rim: Entity. Role, or Act workflow: Event rim: Coverage
id	Σ	0..1	string	There are no (further) constraints on this element Element id Coverage.id Short description Logical id of this artifact Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. Comments The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Data type string
meta	Σ	0..1	Meta	There are no (further) constraints on this element Element id Coverage.meta Short description Metadata about the resource Definition The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. Data type Meta Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
implicitRules	Σ ?!	0..1	uri	There are no (further) constraints on this element Element id Coverage.implicitRules Short description A set of rules under which this content was created Definition A 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. Comments 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. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
language		0..1	codeBinding	There are no (further) constraints on this element Element id Coverage.language Short description Language of the resource content Definition The base language in which the resource is written. Comments 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). Data type code Binding A human language. CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
text		0..1	Narrative	There are no (further) constraints on this element Element id Coverage.text Short description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition A 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. Comments 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. Data type Narrative Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: Act.text?
contained		0..*	Resource	There are no (further) constraints on this element Element id Coverage.contained Short description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition These 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. Comments 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. Data type Resource Mappings rim: N/A
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Coverage.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May 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. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
modifierExtension	?! I	0..*	Extension	There are no (further) constraints on this element Element id Coverage.modifierExtension Short description Extensions that cannot be ignored Alternate names extensions, user content Definition May 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). Requirements 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. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
identifier	Σ	0..*	Identifier	There are no (further) constraints on this element Element id Coverage.identifier Short description Business Identifier for the coverage Definition A unique identifier assigned to this coverage. Requirements Allows coverages to be distinguished and referenced. Comments 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. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.identifier w5: FiveWs.identifier cdanetv4: C02 v2: IN1-2 rim: .id cpha3pharm: C.32, C.33, C.39
status	S Σ ?!	1..1	codeBinding	Element id Coverage.status Short description Status Definition The status of the resource instance. Requirements 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'. Comments Zeigt den aktuellen Status der Ressource an. WICHTIGER Hinweis für Implementierer: Alle server-seitigen Implementierungen MÜSSEN in der Lage sein, die systemintern möglichen Statuswerte korrekt in FHIR abzubilden, mindestens jedoch den Wert `active`. Alle client-seitigen Implementierungen MÜSSEN in der Lage sein, sämtliche Status-Codes zu interpretieren und dem Anwender in angemessener Form darstellen zu können, beispielsweise durch Ausblenden/Durchstreichen von Ressourcen mit dem status `entered-in-error` und Ausgrauen von Ressourcen, die einen Plan- oder Entwurfs-Status haben. Data type code Binding A code specifying the state of the resource instance. FinancialResourceStatusCodes (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.status w5: FiveWs.status rim: Act.status
type	S Σ	1..1	CodeableConceptBinding	Element id Coverage.type Short description Versicherungsart Definition Art der Versicherung: Selbstzahler, gesetzliche/private Versicherung, Berufsgenossenschaft oder Sozialamt Requirements The order of application of coverages is dependent on the types of coverage. Comments Die Angabe der Versicherungsart dient der Abgrenzung dieser Coverage-Ressource von Selbstzahler- oder gesetzlichen Versicherungsverhältnissen. Begründung Pflichtfeld: Die Angabe der Versicherungsart dient der Unterscheidung, wenn zu einem Patienten mehrere Coverage-Ressourcen hinterlegt sind, z.B. gesetzliche Versicherung + Sonstige und als Suchkriterium, um gezielt nach der in einem konkreten Kontext relevanten Coverage suchen zu können. Historie: 28.07.2017 (zulip): TC Konsens bzgl. Verwendung eines eigenen ValueSets anstelle des im Standard definierten preferred bindings, da die dortigen Codes nicht passen. Data type CodeableConcept Binding Art der Versicherung: Selbstzahler, gesetzliche/private Versicherung, Berufsgenossenschaft oder Sozialamt VersicherungsartDeBasis (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.class v2: IN1-15
policyHolder	Σ	0..0	Reference(Patient \| RelatedPerson \| Organization)	There are no (further) constraints on this element Element id Coverage.policyHolder Short description Owner of the policy Definition The party who 'owns' the insurance policy. Requirements This provides employer information in the case of Worker's Compensation and other policies. Comments Es gibt derzeit in DE keine Verwendung für dieses Attribut (Konsens Interop-Forum 12.6.2017) Falls es UseCases gibt, die dieses Attribut benötigen, bitte Info auf chat.fhir.org Data type Reference(Patient \| RelatedPerson \| Organization) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.subject[x] cdanetv4: D01 through D09 v2: IN1-16, 18, 19-name of insured, address, date of birth cpha3pharm: C.35 w5: FiveWs.subject
subscriber	Σ	0..1	Reference(Patient \| RelatedPerson)	There are no (further) constraints on this element Element id Coverage.subscriber Short description Hauptversicherte Person / Mitglied Definition Hauptversicherte Person (ggf. abweichend von beneficiary), z.B. bei Familienversicherung Requirements This is the party who is entitled to the benfits under the policy. Comments May be self or a parent in the case of dependants. Data type Reference(Patient \| RelatedPerson) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.subject[x] cdanetv4: D01 through D09 v2: IN1-16, 18, 19-name of insured, address, date of birth cpha3pharm: C.35 w5: FiveWs.subject
subscriberId	Σ	0..0	string	There are no (further) constraints on this element Element id Coverage.subscriberId Short description ID assigned to the subscriber Definition The insurer assigned ID for the Subscriber. Requirements The insurer requires this identifier on correspondance and claims (digital and otherwise). Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.subject[x] cdanetv4: D01 through D09 v2: IN1-16, 18, 19-name of insured, address, date of birth cpha3pharm: C.35 w5: FiveWs.subject
beneficiary	S Σ	1..1	Reference(Patient)	Element id Coverage.beneficiary Short description Begünstigte Person Definition Person, auf die sich die Kostenübernahme bezieht (der Patient) Requirements This is the party who receives treatment for which the costs are reimbursed under the coverage. Comments Hier handelt es ich konkret um den Patienten, für den die Kostenübernahme gilt. Data type Reference(Patient) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.subject w5: FiveWs.subject[x] cdanetv4: D01 through D09 v2: IN1-16, 18, 19-name of insured, address, date of birth cpha3pharm: C.35 w5: FiveWs.subject
id		0..1	string	There are no (further) constraints on this element Element id Coverage.beneficiary.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Coverage.beneficiary.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May 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. Comments 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
reference	S Σ I	1..1	string	Element id Coverage.beneficiary.reference Short description Patienten-Link Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Die Verlinkung auf eine Patienten-Ressource dient der technischen Zuordnung der Dokumentation zu einem Patienten und ermöglicht wichtige API-Funktionen wie verkettete Suche, (Reverse-)Include etc. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: N/A
type	Σ	0..1	uriBinding	There are no (further) constraints on this element Element id Coverage.beneficiary.type Short description Type the reference refers to (e.g. "Patient") Definition The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). Comments This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Data type uri Binding Aa resource (or, for logical models, the URI of the logical model). ResourceType (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: N/A
identifier	Σ	0..1	Identifier	There are no (further) constraints on this element Element id Coverage.beneficiary.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation\|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .identifier
display	Σ	0..1	string	There are no (further) constraints on this element Element id Coverage.beneficiary.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: N/A
dependent	Σ	0..1	string	There are no (further) constraints on this element Element id Coverage.dependent Short description Dependent number Definition A unique identifier for a dependent under the coverage. Requirements For some coverages a single identifier is issued to the Subscriber and then a unique dependent number is issued to each beneficiary. Comments Periodically the member number is constructed from the subscriberId and the dependant number. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings cdanetv4: C17 v2: - No exact HL7 v2 equivalent concept seems to exist;
relationship		0..1	CodeableConceptBinding	There are no (further) constraints on this element Element id Coverage.relationship Short description Beneficiary relationship to the subscriber Definition The relationship of beneficiary (patient) to the subscriber. Requirements To determine relationship between the patient and the subscriber to determine coordination of benefits. Comments Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others. Data type CodeableConcept Binding The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). SubscriberRelationshipCodes (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings cdanetv4: C03
period	Σ	0..1	Period	There are no (further) constraints on this element Element id Coverage.period Short description Coverage start and end dates Definition Time 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. Requirements Some insurers require the submission of the coverage term. Data type Period Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.occurrence[x] w5: FiveWs.done[x] v2: IN1-12 / IN1-13 rim: Act.effectiveTime
payor	S Σ	1..*	Reference(Patient \| RelatedPerson \| Organization)	Element id Coverage.payor Short description Kostenträger Definition Versicherer, der die Police ausgegeben hat oder Persopn/Organisation, die die Kosten übernimmt. Requirements Need to identify the issuer to target for claim processing and for coordination of benefit processing. Comments Ein sonstiger Kostenträger kann eine Person oder eine Organisation (z.B. Botschaft/Amt) sein. Data type Reference(Patient \| RelatedPerson \| Organization) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.author cdanetv4: A05 v2: IN1-3 cpha3pharm: C.30
id		0..1	string	There are no (further) constraints on this element Element id Coverage.payor.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Coverage.payor.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May 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. Comments 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
reference	Σ I	0..1	string	There are no (further) constraints on this element Element id Coverage.payor.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: N/A
type	Σ	0..1	uriBinding	There are no (further) constraints on this element Element id Coverage.payor.type Short description Type the reference refers to (e.g. "Patient") Definition The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). Comments This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Data type uri Binding Aa resource (or, for logical models, the URI of the logical model). ResourceType (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: N/A
identifier	Σ	0..1	Identifier	There are no (further) constraints on this element Element id Coverage.payor.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation\|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .identifier
display	S Σ	0..1	string	Element id Coverage.payor.display Short description Kostenträger-Bezeichnung Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments Name des Kostenträgers Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: N/A
class		0..*	BackboneElement	There are no (further) constraints on this element Element id Coverage.class Short description Additional coverage classifications Definition A suite of underwriter specific classifiers. Requirements The codes provided on the health card which identify or confirm the specific policy for the insurer. Comments For example may be used to identify a class of coverage or employer group, Policy, Plan. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id Coverage.class.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Coverage.class.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May 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. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Coverage.class.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May 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). Requirements 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. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
type	Σ	1..1	CodeableConceptBinding	There are no (further) constraints on this element Element id Coverage.class.type Short description Type of class such as 'group' or 'plan' Definition The 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. Requirements The insurer issued label for a specific health card value. Data type CodeableConcept Binding The policy classifications, eg. Group, Plan, Class, etc. CoverageClassCodes (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
value	Σ	1..1	string	There are no (further) constraints on this element Element id Coverage.class.value Short description Value associated with the type Definition The alphanumeric string value associated with the insurer issued label. Requirements The insurer issued label and value are necessary to identify the specific policy. Comments For example, the Group or Plan number. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings cdanetv4: C11 (Division,Section) v2: IN1-8 cpha3pharm: C.31
name	Σ	0..1	string	There are no (further) constraints on this element Element id Coverage.class.name Short description Human readable description of the type and value Definition A short description for the class. Requirements Used to provide a meaningful description in correspondence to the patient. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings cdanetv4: C11 (Division,Section) v2: IN1-8 cpha3pharm: C.31
order	Σ	0..0	positiveInt	There are no (further) constraints on this element Element id Coverage.order Short description Relative order of the coverage Definition The 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. Requirements Used in managing the coordination of benefits. Comments Es git derzeit in DE keine Verwendung für dieses Attribut (Konsens Interop-Forum 12.6.2017) Für die Priorisierung der Versicherungsverhältnisse sollte statt dessen Account.coverage.priority verwendet werden, da die Priorisierung abhängig von Fall- und Abrechnungsart unterschiedlich sein kann. Falls es UseCases gibt, die dieses Attribut benötigen, bitte Info auf chat.fhir.org Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: - No exact HL7 v2 equivalent concept seems to exist;
network	Σ	0..0	string	There are no (further) constraints on this element Element id Coverage.network Short description Insurer network Definition Die Versicherungsleistungen sind an ein bestimmtes Netzwerk von Gesundheitsdienstleistern gebunden Requirements Used in referral for treatment and in claims processing. Comments Es gibt derzeit in DE keine Verwendung für dieses Attribut (Konsens Interop-Forum 12.6.2017) Falls es UseCases gibt, die dieses Attribut benötigen, bitte Info auf chat.fhir.org Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings cdanetv4: D10
costToBeneficiary		0..*	BackboneElement	There are no (further) constraints on this element Element id Coverage.costToBeneficiary Short description Patient payments for services/products Alternate names CoPay, Deductible, Exceptions Definition A 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. Requirements Required by providers to manage financial transaction with the patient. Comments For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id Coverage.costToBeneficiary.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Coverage.costToBeneficiary.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May 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. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Coverage.costToBeneficiary.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May 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). Requirements 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. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
type	Σ	0..1	CodeableConceptBinding	There are no (further) constraints on this element Element id Coverage.costToBeneficiary.type Short description Cost category Definition The category of patient centric costs associated with treatment. Requirements Needed to identify the category associated with the amount for the patient. Comments For example visit, specialist visits, emergency, inpatient care, etc. Data type CodeableConcept Binding The types of services to which patient copayments are specified. CoverageCopayTypeCodes (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
value[x]	Σ	1..1		There are no (further) constraints on this element Element id Coverage.costToBeneficiary.value[x] Short description The amount or percentage due from the beneficiary Definition The amount due from the patient for the cost category. Requirements Needed to identify the amount for the patient associated with the category. Comments Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings cdanetv4: C11 (Division,Section) v2: IN1-8 cpha3pharm: C.31
valueQuantity			SimpleQuantity	There are no (further) constraints on this element Data type SimpleQuantity
valueMoney			Money	There are no (further) constraints on this element Data type Money
exception		0..*	BackboneElement	There are no (further) constraints on this element Element id Coverage.costToBeneficiary.exception Short description Exceptions for patient payments Definition A suite of codes indicating exceptions or reductions to patient costs and their effective periods. Requirements Required by providers to manage financial transaction with the patient. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id Coverage.costToBeneficiary.exception.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Coverage.costToBeneficiary.exception.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May 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. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Coverage.costToBeneficiary.exception.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May 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). Requirements 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. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
type	Σ	1..1	CodeableConcept	There are no (further) constraints on this element Element id Coverage.costToBeneficiary.exception.type Short description Exception category Definition The code for the specific exception. Requirements Needed to identify the exception associated with the amount for the patient. Data type CodeableConcept Binding The types of exceptions from the part or full value of financial obligations such as copays. ExampleCoverageFinancialExceptionCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
period	Σ	0..1	Period	There are no (further) constraints on this element Element id Coverage.costToBeneficiary.exception.period Short description The effective period of the exception Definition The timeframe during when the exception is in force. Requirements Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs. Data type Period Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
subrogation		0..1	boolean	There are no (further) constraints on this element Element id Coverage.subrogation Short description Reimbursement to insurer Definition When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs. Requirements See definition for when to be used. Comments Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims. Data type boolean Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
contract		0..*	Reference(Contract)	There are no (further) constraints on this element Element id Coverage.contract Short description Contract details Definition The policy(s) which constitute this insurance coverage. Requirements To reference the legally binding contract between the policy holder and the insurer. Data type Reference(Contract) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings cdanetv4: D01 through D09 v2: IN1-16, 18, 19 rim: n/a cpha3pharm: C.35

<StructureDefinition xmlns="http://hl7.org/fhir">
    <id value="ISiKVersicherungsverhaeltnisSonstige" />
    <url value="https://gematik.de/fhir/isik/StructureDefinition/ISiKVersicherungsverhaeltnisSonstige" />
    <version value="5.0.0-rc" />
    <name value="ISiKVersicherungsverhaeltnisSonstige" />
    <status value="active" />
    <experimental value="false" />
    <date value="2025-04-09" />
    <publisher value="gematik GmbH" />
    <description value="Dieses Profil erm&#246;glicht die Darstellung sonstiger Versicherungsverh&#228;ltnisses in ISiK Szenarien.  \n### Motivation\nISiK unterst&#252;tzt Anwendungsszenarien, in denen durch das Krankenhaus erbrachte Leistungen erfasst oder gegen&#252;ber Kostentr&#228;gern abgerechnet werden, \nbei denen es sich *weder* um gesetzliche Versicherungen noch Selbstzahlerverh&#228;ltnisse handelt.\nIn diesen Anwendungsszenarien wird das Versicherungsverh&#228;ltnis verwendet, um bspw. den Versicherungsstatus oder die Rechnungsanschrift der Versicherung zu ermitteln.  \nIn FHIR werden Versicherungsverh&#228;ltnisse mit der Coverage-Ressource repr&#228;sentiert.\n\n### Kompatibilit&#228;t\nDas Profil ISiKVersicherungsverhaeltnisSonstige basiert auf dem [Basis-Coverage-Profil der deutschen Basisprofile](http://fhir.de/StructureDefinition/coverage-de-basis). \n\nHinweise zu Inkompatibilit&#228;ten k&#246;nnen &#252;ber die [Portalseite](https://service.gematik.de/servicedesk/customer/portal/16) gemeldet werden." />
    <fhirVersion value="4.0.1" />
    <kind value="resource" />
    <abstract value="false" />
    <type value="Coverage" />
    <baseDefinition value="http://fhir.de/StructureDefinition/coverage-de-basis" />
    <derivation value="constraint" />
    <differential>
        <element id="Coverage.status">
            <path value="Coverage.status" />
            <short value="Status" />
            <comment value="Zeigt den aktuellen Status der Ressource an.     \n  **WICHTIGER Hinweis f&#252;r Implementierer:**    \n  * Alle server-seitigen Implementierungen M&#220;SSEN in der Lage sein, \n  die systemintern m&#246;glichen Statuswerte korrekt in FHIR abzubilden, mindestens jedoch den Wert `active`.\n  * Alle client-seitigen Implementierungen M&#220;SSEN in der Lage sein, s&#228;mtliche Status-Codes zu interpretieren und dem Anwender in angemessener Form darstellen zu k&#246;nnen, \n  beispielsweise durch Ausblenden/Durchstreichen von Ressourcen mit dem status `entered-in-error` und Ausgrauen von Ressourcen, die einen Plan- oder Entwurfs-Status haben." />
            <mustSupport value="true" />
        </element>
        <element id="Coverage.type">
            <path value="Coverage.type" />
            <comment value="Die Angabe der Versicherungsart dient der Abgrenzung dieser Coverage-Ressource von Selbstzahler- oder gesetzlichen Versicherungsverh&#228;ltnissen.  \n  **Begr&#252;ndung Pflichtfeld:** Die Angabe der Versicherungsart dient der Unterscheidung, wenn zu einem Patienten mehrere Coverage-Ressourcen hinterlegt sind, \n  z.B. gesetzliche Versicherung + Sonstige und als Suchkriterium, um gezielt nach der in einem konkreten Kontext relevanten Coverage suchen zu k&#246;nnen.  \n  **Historie:**  \n  28.07.2017 (zulip): TC Konsens bzgl. Verwendung eines eigenen ValueSets anstelle des im Standard definierten preferred bindings, da die dortigen Codes nicht passen." />
            <mustSupport value="true" />
        </element>
        <element id="Coverage.beneficiary">
            <path value="Coverage.beneficiary" />
            <comment value="Hier handelt es ich konkret um den Patienten, f&#252;r den die Kosten&#252;bernahme gilt." />
            <mustSupport value="true" />
        </element>
        <element id="Coverage.beneficiary.reference">
            <path value="Coverage.beneficiary.reference" />
            <short value="Patienten-Link" />
            <comment value="Die Verlinkung auf eine Patienten-Ressource dient der technischen Zuordnung der Dokumentation zu einem Patienten \n    und erm&#246;glicht wichtige API-Funktionen wie verkettete Suche, (Reverse-)Include etc." />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="Coverage.payor">
            <path value="Coverage.payor" />
            <short value="Kostentr&#228;ger" />
            <comment value="Ein sonstiger Kostentr&#228;ger kann eine Person oder eine Organisation (z.B. Botschaft/Amt) sein." />
            <type>
                <code value="Reference" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/RelatedPerson" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Organization" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="Coverage.payor.display">
            <path value="Coverage.payor.display" />
            <short value="Kostentr&#228;ger-Bezeichnung" />
            <comment value="Name des Kostentr&#228;gers" />
            <mustSupport value="true" />
        </element>
    </differential>
</StructureDefinition>

{
    "resourceType": "StructureDefinition",
    "id": "ISiKVersicherungsverhaeltnisSonstige",
    "url": "https://gematik.de/fhir/isik/StructureDefinition/ISiKVersicherungsverhaeltnisSonstige",
    "version": "5.0.0-rc",
    "name": "ISiKVersicherungsverhaeltnisSonstige",
    "status": "active",
    "experimental": false,
    "date": "2025-04-09",
    "publisher": "gematik GmbH",
    "description": "Dieses Profil ermöglicht die Darstellung sonstiger Versicherungsverhältnisses in ISiK Szenarien.  \n### Motivation\nISiK unterstützt Anwendungsszenarien, in denen durch das Krankenhaus erbrachte Leistungen erfasst oder gegenüber Kostenträgern abgerechnet werden, \nbei denen es sich *weder* um gesetzliche Versicherungen noch Selbstzahlerverhältnisse handelt.\nIn diesen Anwendungsszenarien wird das Versicherungsverhältnis verwendet, um bspw. den Versicherungsstatus oder die Rechnungsanschrift der Versicherung zu ermitteln.  \nIn FHIR werden Versicherungsverhältnisse mit der Coverage-Ressource repräsentiert.\n\n### Kompatibilität\nDas Profil ISiKVersicherungsverhaeltnisSonstige basiert auf dem [Basis-Coverage-Profil der deutschen Basisprofile](http://fhir.de/StructureDefinition/coverage-de-basis). \n\nHinweise zu Inkompatibilitäten können über die [Portalseite](https://service.gematik.de/servicedesk/customer/portal/16) gemeldet werden.",
    "fhirVersion": "4.0.1",
    "kind": "resource",
    "abstract": false,
    "type": "Coverage",
    "baseDefinition": "http://fhir.de/StructureDefinition/coverage-de-basis",
    "derivation": "constraint",
    "differential": {
        "element":  [
            {
                "id": "Coverage.status",
                "path": "Coverage.status",
                "short": "Status",
                "comment": "Zeigt den aktuellen Status der Ressource an.     \n  **WICHTIGER Hinweis für Implementierer:**    \n  * Alle server-seitigen Implementierungen MÜSSEN in der Lage sein, \n  die systemintern möglichen Statuswerte korrekt in FHIR abzubilden, mindestens jedoch den Wert `active`.\n  * Alle client-seitigen Implementierungen MÜSSEN in der Lage sein, sämtliche Status-Codes zu interpretieren und dem Anwender in angemessener Form darstellen zu können, \n  beispielsweise durch Ausblenden/Durchstreichen von Ressourcen mit dem status `entered-in-error` und Ausgrauen von Ressourcen, die einen Plan- oder Entwurfs-Status haben.",
                "mustSupport": true
            },
            {
                "id": "Coverage.type",
                "path": "Coverage.type",
                "comment": "\n  Die Angabe der Versicherungsart dient der Abgrenzung dieser Coverage-Ressource von Selbstzahler- oder gesetzlichen Versicherungsverhältnissen.  \n  **Begründung Pflichtfeld:** Die Angabe der Versicherungsart dient der Unterscheidung, wenn zu einem Patienten mehrere Coverage-Ressourcen hinterlegt sind, \n  z.B. gesetzliche Versicherung + Sonstige und als Suchkriterium, um gezielt nach der in einem konkreten Kontext relevanten Coverage suchen zu können.  \n  **Historie:**  \n  28.07.2017 (zulip): TC Konsens bzgl. Verwendung eines eigenen ValueSets anstelle des im Standard definierten preferred bindings, da die dortigen Codes nicht passen.",
                "mustSupport": true
            },
            {
                "id": "Coverage.beneficiary",
                "path": "Coverage.beneficiary",
                "comment": "Hier handelt es ich konkret um den Patienten, für den die Kostenübernahme gilt.",
                "mustSupport": true
            },
            {
                "id": "Coverage.beneficiary.reference",
                "path": "Coverage.beneficiary.reference",
                "short": "Patienten-Link",
                "comment": "Die Verlinkung auf eine Patienten-Ressource dient der technischen Zuordnung der Dokumentation zu einem Patienten \n    und ermöglicht wichtige API-Funktionen wie verkettete Suche, (Reverse-)Include etc.",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "Coverage.payor",
                "path": "Coverage.payor",
                "short": "Kostenträger",
                "comment": "Ein sonstiger Kostenträger kann eine Person oder eine Organisation (z.B. Botschaft/Amt) sein.",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "http://hl7.org/fhir/StructureDefinition/Patient",
                            "http://hl7.org/fhir/StructureDefinition/RelatedPerson",
                            "http://hl7.org/fhir/StructureDefinition/Organization"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Coverage.payor.display",
                "path": "Coverage.payor.display",
                "short": "Kostenträger-Bezeichnung",
                "comment": "Name des Kostenträgers",
                "mustSupport": true
            }
        ]
    }
}

ISiKVersicherungsverhaeltnisSonstige

Anmerkungen zu Must-Support-Feldern

Feldname	Kurzbeschreibung	Hinweise
Coverage.status	Status	Zeigt den aktuellen Status der Ressource an. WICHTIGER Hinweis für Implementierer: Alle server-seitigen Implementierungen MÜSSEN in der Lage sein, die systemintern möglichen Statuswerte korrekt in FHIR abzubilden, mindestens jedoch den Wert `active`. Alle client-seitigen Implementierungen MÜSSEN in der Lage sein, sämtliche Status-Codes zu interpretieren und dem Anwender in angemessener Form darstellen zu können, beispielsweise durch Ausblenden/Durchstreichen von Ressourcen mit dem status `entered-in-error` und Ausgrauen von Ressourcen, die einen Plan- oder Entwurfs-Status haben.
Coverage.type		Die Angabe der Versicherungsart dient der Abgrenzung dieser Coverage-Ressource von Selbstzahler- oder gesetzlichen Versicherungsverhältnissen. Begründung Pflichtfeld: Die Angabe der Versicherungsart dient der Unterscheidung, wenn zu einem Patienten mehrere Coverage-Ressourcen hinterlegt sind, z.B. gesetzliche Versicherung + Sonstige und als Suchkriterium, um gezielt nach der in einem konkreten Kontext relevanten Coverage suchen zu können. Historie: 28.07.2017 (zulip): TC Konsens bzgl. Verwendung eines eigenen ValueSets anstelle des im Standard definierten preferred bindings, da die dortigen Codes nicht passen.
Coverage.beneficiary		Hier handelt es ich konkret um den Patienten, für den die Kostenübernahme gilt.
Coverage.beneficiary.reference	Patienten-Link	Die Verlinkung auf eine Patienten-Ressource dient der technischen Zuordnung der Dokumentation zu einem Patienten und ermöglicht wichtige API-Funktionen wie verkettete Suche, (Reverse-)Include etc.
Coverage.payor	Kostenträger	Ein sonstiger Kostenträger kann eine Person oder eine Organisation (z.B. Botschaft/Amt) sein.
Coverage.payor.display	Kostenträger-Bezeichnung	Name des Kostenträgers

Interaktionen

Interaktion	Verbindlichkeit
read	SHALL
search-type	SHALL

Parameter	Typ	Verbindlichkeit	Hinweise
_id	token	SHALL	Beispiel: `GET [base]/[Resourcetype]?_id=103270` Anwendungshinweis: Der Parameter `_id` wird selten alleinstehend verwendet, da sich zum Abruf einer Ressource anhand der `id` die `READ`-Interaktion besser anbietet. Der Parameter kann jedoch verwendet werden, um den Abruf einer Ressource bspw. mit einem `_include` weiterer Ressourcen zu verbinden, z.B. zum Abruf eines Encounters in Verbindung mit dem zugehörigen Patienten: `GET [base]/Encounter?_id=103270&_include=Encounter:patient` Weitere Details siehe FHIR-Kernspezifikation, Abschnitt Parameters for all resources. Dieser Suchparameter ist für die Umsetzung des IHE PDQm Profils verpflichtend.
_tag	token	SHALL	Beispiel: `GET [base]/[Resourcetype]?_tag=https://example.org/codes\|needs-review` Anwendungshinweis: Weitere Details siehe FHIR-Kernspezifikation, Abschnitt Parameters for all resources sowie Abschnitt Tags.
_count	number	SHALL	Beispiel: `GET [base]/[Resourcetype]?_count=100` Anwendungshinweis: Weitere Details siehe FHIR-Kernspezifikation, Abschnitt Page Count.
_has	string	MAY	Beispiel: Suche nach allen Patienten, die eine Observation mit dem Code '1234-5' haben `GET [base]/Patient?_has:Observation:patient:code=1234-5` Beispiel: Suche nach allen Encountern, bei denen die Diagnose 'A12.3' gestellt wurde `GET [base]/Encounter?_has:Condition:encounter:code=A12.3` Anwendungshinweis: Weitere Details siehe FHIR-Kernspezifikation, Abschnitt Reverse Chaining.
status	token	SHALL	Beispiel: `GET [base]/Coverage?status=active` Anwendungshinweis: Weitere Details siehe FHIR-Kernspezifikation.
type	token	SHALL	Beispiel: `GET [base]/Coverage?type=http://fhir.de/CodeSystem/versicherungsart-de-basis\|GKV` Anwendungshinweis: Weitere Details siehe FHIR-Kernspezifikation.
beneficiary	reference	SHALL	Beispiel: `GET [base]/Coverage?beneficiary=Patient/123` Anwendungshinweis: Weitere Details siehe FHIR-Kernspezifikation.
payor	reference	SHALL	Beispiel: `GET [base]/Coverage?payor:identifier=0123456789` Anwendungshinweis: Weitere Details siehe FHIR-Kernspezifikation.
subscriber	reference	MAY	Beispiel: `GET [base]/Coverage?subscriber=Patient/123` Anwendungshinweis: Weitere Details siehe FHIR-Kernspezifikation.

(Reverse-)Include

Include
Coverage:subscriber; Coverage:patient; Coverage:payor; Coverage:beneficiary

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Beispiele

Valides Minimalbeispiel:

Coverage

id : CoverageSonstige

meta

status : active

type

beneficiary

payor

<Coverage xmlns="http://hl7.org/fhir">
    <id value="CoverageSonstige" />
    <meta>
        <profile value="https://gematik.de/fhir/isik/StructureDefinition/ISiKVersicherungsverhaeltnisSonstige" />
    </meta>
    <status value="active" />
    <type>
        <coding>
            <system value="http://fhir.de/CodeSystem/versicherungsart-de-basis" />
            <code value="SOZ" />
        </coding>
    </type>
    <beneficiary>
        <reference value="Patient/PatientinMusterfrau" />
    </beneficiary>
    <payor>
        <display value="Sozialamt Posemuckel" />
    </payor>
</Coverage>

{
    "resourceType": "Coverage",
    "id": "CoverageSonstige",
    "meta": {
        "profile":  [
            "https://gematik.de/fhir/isik/StructureDefinition/ISiKVersicherungsverhaeltnisSonstige"
        ]
    },
    "status": "active",
    "type": {
        "coding":  [
            {
                "code": "SOZ",
                "system": "http://fhir.de/CodeSystem/versicherungsart-de-basis"
            }
        ]
    },
    "beneficiary": {
        "reference": "Patient/PatientinMusterfrau"
    },
    "payor":  [
        {
            "display": "Sozialamt Posemuckel"
        }
    ]
}

CoverageSonstige