{ "resourceType": "StructureDefinition", "id": "ocp-coverage", "meta": { "versionId": "1", "lastUpdated": "2017-04-18T21:44:43.294+00:00" }, "language": "US-en", "text": { "status": "generated", "div": "
\nThe FHIR STU3 (Release 3) Omnibus Care Plan (OCP) Coverage profile is intended to provide the high level identifiers and potentially descriptors of an insurance plan which may be used to pay for, in part or in whole, the provision of health care products and services. This profile may also be used to register 'SelfPay' where an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs.\nIt identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile.\nThe supported data elements to the OCP Coverage profile are listed below:\nstatus, type, subscriber, subscriberId, beneficiary, relationship, and period.\nDependencies:\n Coverage profile that conforms to this specification must include reference to other resources \n
" }, "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm", "valueInteger": 2 }, { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg", "valueCode": "fm" } ], "url": "http://hl7.org/fhir/StructureDefinition/ocp-coverage", "version": "1.0", "name": "OCP Coverage Profile", "title": "OCP Coverage Profile", "status": "draft", "date": "2017-04-18T21:44:43+00:00", "publisher": "SAMHSA", "contact": [ { "name": "Neelima Chennamaraja, Ioana Singureanu", "telecom": [ { "system": "url", "value": "www.eversolve.com", "period": { "start": "1999-06-15" } }, { "system": "email", "value": "neelima@eversolve.com", "use": "work" }, { "system": "email", "value": "ioana@eversolve.com", "use": "work" } ] } ], "description": "This profile describes minimum expectations for the Coverage resource to record, search and fetch basic reimbursements or payment for health care products and services about an individual Omnibus Care Plan (OCP) patient. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile.\r\nBase StructureDefinition for Coverage Resource.", "jurisdiction": [ { "coding": [ { "code": "US", "display": "US-Realm" } ], "text": "US-Realm OCP Coverage Profile published by SAMHSA" } ], "purpose": "This profile is intended to be implemented by OCP (Omnibus Care Plan) systems for Health care programs and insurers are significant payors of health service costs.", "copyright": "+Copyright (c) 2017 SAMHSA. All Rights Reserved.", "fhirVersion": "3.0.1", "mapping": [ { "identity": "workflow", "uri": "http://hl7.org/fhir/workflow", "name": "Workflow Mapping" }, { "identity": "rim", "uri": "http://hl7.org/v3", "name": "RIM Mapping" }, { "identity": "w5", "uri": "http://hl7.org/fhir/w5", "name": "W5 Mapping" }, { "identity": "cdanetv4", "uri": "http://www.cda-adc.ca/en/services/cdanet/", "name": "Canadian Dental Association eclaims standard" }, { "identity": "v2", "uri": "http://hl7.org/v2", "name": "HL7 v2 Mapping" }, { "identity": "cpha3pharm", "uri": "http://www.pharmacists.ca/", "name": "Canadian Pharmacy Associaiton eclaims standard" } ], "kind": "resource", "abstract": false, "type": "Coverage", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource", "derivation": "specialization", "snapshot": { "element": [ { "id": "Coverage", "path": "Coverage", "short": "Insurance or medical plan or a payment agreement", "definition": "Financial instrument which may be used to reimburse or pay for health care products and services.", "min": 0, "max": "*", "base": { "path": "Resource", "min": 0, "max": "*" }, "constraint": [ { "key": "dom-2", "severity": "error", "human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources", "expression": "contained.contained.empty()", "xpath": "not(parent::f:contained and f:contained)" }, { "key": "dom-1", "severity": "error", "human": "If the resource is contained in another resource, it SHALL NOT contain any narrative", "expression": "contained.text.empty()", "xpath": "not(parent::f:contained and f:text)" }, { "key": "dom-4", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated", "expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()", "xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))" }, { "key": "dom-3", "severity": "error", "human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource", "expression": "contained.where(('#'+id in %resource.descendants().reference).not()).empty()", "xpath": "not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))" } ], "mapping": [ { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "workflow", "map": "Event" }, { "identity": "rim", "map": "Coverage" }, { "identity": "w5", "map": "financial.support" } ] }, { "id": "Coverage.id", "path": "Coverage.id", "short": "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.", "comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.", "min": 0, "max": "1", "base": { "path": "Resource.id", "min": 0, "max": "1" }, "type": [ { "code": "id" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Coverage.meta", "path": "Coverage.meta", "short": "Metadata about the resource", "definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.", "min": 0, "max": "1", "base": { "path": "Resource.meta", "min": 0, "max": "1" }, "type": [ { "code": "Meta" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Coverage.implicitRules", "path": "Coverage.implicitRules", "short": "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.", "comment": "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. \n\nThis element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.", "min": 0, "max": "1", "base": { "path": "Resource.implicitRules", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "isModifier": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Coverage.language", "path": "Coverage.language", "short": "Language of the resource content", "definition": "The base language in which the resource is written.", "comment": "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).", "min": 0, "max": "1", "base": { "path": "Resource.language", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet", "valueReference": { "reference": "http://hl7.org/fhir/ValueSet/all-languages" } }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Language" }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding", "valueBoolean": true } ], "strength": "extensible", "description": "A human language.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/languages" } }, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Coverage.text", "path": "Coverage.text", "short": "Text summary of the resource, for human interpretation", "definition": "A human-readable narrative that contains a summary of the resource, and may 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.", "comment": "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 in formation is added later.", "alias": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "base": { "path": "DomainResource.text", "min": 0, "max": "1" }, "type": [ { "code": "Narrative" } ], "condition": [ "ele-1", "dom-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" }, { "identity": "rim", "map": "Act.text?" } ] }, { "id": "Coverage.contained", "path": "Coverage.contained", "short": "Contained, inline 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.", "comment": "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.", "alias": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "base": { "path": "DomainResource.contained", "min": 0, "max": "*" }, "type": [ { "code": "Resource" } ], "mapping": [ { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Coverage.extension", "path": "Coverage.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order 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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Coverage.modifierExtension", "path": "Coverage.modifierExtension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Extensions that cannot be ignored", "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. Usually modifier elements provide negation or qualification. In order 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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])" } ], "isModifier": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Coverage.Identifier", "path": "Coverage.identifier", "short": "The primary coverage ID", "definition": "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 concatination of the Coverage.SubscriberID and the Coverage.dependant.", "comment": "This data element is supported but it's optional.", "requirements": "This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below.", "min": 0, "max": "*", "type": [ { "code": "Identifier" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" }, { "identity": "workflow", "map": "Event.identifier" }, { "identity": "cdanetv4", "map": "C02" }, { "identity": "v2", "map": "IN1-2" }, { "identity": "cpha3pharm", "map": "C.32, C.33, C.39" }, { "identity": "w5", "map": "id" } ] }, { "id": "Coverage.code", "path": "Coverage.status", "short": "active | cancelled | draft | entered-in-error", "definition": "The status of the resource instance. User selected status.", "comment": "This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mustSupport": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "CoverageStatus" } ], "strength": "required", "description": "A code specifying the state of the resource instance.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/fm-status" } }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.status" }, { "identity": "w5", "map": "status" } ] }, { "id": "Coverage.CodeableConcept", "path": "Coverage.type", "short": "Type of coverage such as medical or accident", "definition": "The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization. For now will use the list from FHIR. However, this is very long list and not very intuitive. We may consider using a smaller subset after following up with SMEs.", "comment": "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.", "requirements": "The order of application of coverages is dependent on the types of coverage.", "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mustSupport": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "CoverageType" } ], "strength": "preferred", "description": "The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/coverage-type" } }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "IN1-15" }, { "identity": "w5", "map": "class" } ] }, { "id": "Coverage.Reference", "path": "Coverage.Reference", "short": "Owner of the policy", "definition": "The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer.This may be needed for insurance through employer but otherwise it will be same as subscriber so we can consider this at later time. It will be questionable how all employer organizations are added in OCP to make it work.", "comment": "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.", "min": 0, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ocp-patient" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ocp-relatedperson" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "cdanetv4", "map": "D01 through D09" }, { "identity": "v2", "map": "IN1-16, 18, 19-name of insured, address, date of birth" }, { "identity": "cpha3pharm", "map": "C.35" }, { "identity": "w5", "map": "who.focus" } ] }, { "id": "Coverage.Reference", "path": "Coverage.subscriber", "short": "Subscriber to the policy", "definition": "The 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. Default to Patient but user can choose related person who is the subscriber or primary insured person.", "comment": "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.", "min": 1, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ocp-patient" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ocp-relatedperson" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])" } ], "mustSupport": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "cdanetv4", "map": "D01 through D09" }, { "identity": "v2", "map": "IN1-16, 18, 19-name of insured, address, date of birth" }, { "identity": "cpha3pharm", "map": "C.35" }, { "identity": "w5", "map": "who.focus" } ] }, { "id": "Coverage.string", "path": "Coverage.subscriberId", "short": "ID assigned to the Subscriber", "definition": "The insurer assigned ID for the Subscriber. Subscriber identifier (e.g. insurance policy, Medicaid #, Medicare #, group policy number etc.)", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 1, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mustSupport": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "cdanetv4", "map": "D01 through D09" }, { "identity": "v2", "map": "IN1-16, 18, 19-name of insured, address, date of birth" }, { "identity": "cpha3pharm", "map": "C.35" }, { "identity": "w5", "map": "who.focus" } ] }, { "id": "Coverage.Reference", "path": "Coverage.beneficiary", "short": "Plan Beneficiary", "definition": "The party who benefits from the insurance coverage., the patient when services are provided.", "comment": "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.", "min": 1, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ocp-patient" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])" } ], "mustSupport": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.subject" }, { "identity": "cdanetv4", "map": "D01 through D09" }, { "identity": "v2", "map": "IN1-16, 18, 19-name of insured, address, date of birth" }, { "identity": "cpha3pharm", "map": "C.35" }, { "identity": "w5", "map": "who.focus" } ] }, { "id": "Coverage.CodeableConcept", "path": "Coverage.relationship", "short": "Beneficiary relationship to the Subscriber", "definition": "The relationship of beneficiary (patient) to the subscriber. Use the list from FHIR but default to \"Self\".", "comment": "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.", "requirements": "To determine relationship between the patient and the subscriber.", "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mustSupport": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Relationship" } ], "strength": "example", "description": "The relationship between the Policyholder and the Beneficiary (insured/covered party/patient).", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/policyholder-relationship" } }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "cdanetv4", "map": "C03" } ] }, { "id": "Coverage.Period", "path": "Coverage.period", "short": "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.", "comment": "This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. 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\"). If duration is required, specify the type as Interval|Duration.", "min": 1, "max": "1", "type": [ { "code": "Period" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" }, { "key": "per-1", "severity": "error", "human": "If present, start SHALL have a lower value than end", "expression": "start.empty() or end.empty() or (start <= end)", "xpath": "not(exists(f:start)) or not(exists(f:end)) or (f:start/@value <= f:end/@value)" } ], "mustSupport": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR" }, { "identity": "rim", "map": "IVL[lowClosed=\"true\" and highClosed=\"true\"] or URG[lowClosed=\"true\" and highClosed=\"true\"]" }, { "identity": "workflow", "map": "Event.occurrence" }, { "identity": "v2", "map": "IN1-12 / IN1-13" }, { "identity": "w5", "map": "when.done" } ] }, { "id": "Coverage.period.id", "path": "Coverage.period.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Coverage.period.extension", "path": "Coverage.period.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order 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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Coverage.Period.start", "path": "Coverage.period.start", "short": "Starting time with inclusive boundary", "definition": "The start of the period. The boundary is inclusive. Period.start is required.", "comment": "If the low element is missing, the meaning is that the low boundary is not known.", "min": 1, "max": "1", "base": { "path": "Period.start", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" } ], "condition": [ "ele-1", "per-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR.1" }, { "identity": "rim", "map": "./low" } ] }, { "id": "Coverage.period.end", "path": "Coverage.period.end", "short": "End time with inclusive boundary, if not ongoing", "definition": "The end of the period. If the end of the period is missing, it means that the period is ongoing. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.", "comment": "The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has a end value of 2012-02-03.", "min": 0, "max": "1", "base": { "path": "Period.end", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" } ], "meaningWhenMissing": "If the end of the period is missing, it means that the period is ongoing", "condition": [ "ele-1", "per-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR.2" }, { "identity": "rim", "map": "./high" } ] }, { "id": "Coverage.Reference", "path": "Coverage.payor", "short": "Identifier for the plan or agreement issuer", "definition": "The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements. May provide multiple identifiers such as insurance company identifier or business identifier (BIN number).", "comment": "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.", "requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.", "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ocp-patient" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ocp-relatedperson" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "cdanetv4", "map": "A05" }, { "identity": "v2", "map": "IN1-3" }, { "identity": "cpha3pharm", "map": "C.30" }, { "identity": "w5", "map": "who.author" } ] }, { "id": "Coverage.BackboneElement", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Group" } ], "path": "Coverage.grouping", "short": "Additional coverage classifications", "definition": "A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan.", "min": 0, "max": "1", "type": [ { "code": "BackboneElement" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Coverage.grouping.id", "path": "Coverage.grouping.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "Coverage.grouping.extension", "path": "Coverage.grouping.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order 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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Coverage.grouping.modifierExtension", "path": "Coverage.grouping.modifierExtension", "short": "Extensions that cannot be ignored", "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 that contains it. Usually modifier elements provide negation or qualification. In order 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.", "comment": "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.", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])" } ], "isModifier": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.group", "short": "An identifier for the group", "definition": "Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify an employer group. May also be referred to as a Policy or Group ID.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "cdanetv4", "map": "C11 (Division,Section)" }, { "identity": "v2", "map": "IN1-8" }, { "identity": "cpha3pharm", "map": "C.31" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.groupDisplay", "short": "Display text for an identifier for the group", "definition": "A short description for the group.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "cdanetv4", "map": "C11 (Division,Section)" }, { "identity": "v2", "map": "IN1-8" }, { "identity": "cpha3pharm", "map": "C.31" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.subGroup", "short": "An identifier for the subsection of the group", "definition": "Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a subset of an employer group.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "IN1-8" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.subGroupDisplay", "short": "Display text for the subsection of the group", "definition": "A short description for the subgroup.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "IN1-8" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.plan", "short": "An identifier for the plan", "definition": "Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a collection of benefits provided to employees. May be referred to as a Section or Division ID.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "cdanetv4", "map": "C01" }, { "identity": "v2", "map": "IN1-35" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.planDisplay", "short": "Display text for the plan", "definition": "A short description for the plan.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "cdanetv4", "map": "C01" }, { "identity": "v2", "map": "IN1-35" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.subPlan", "short": "An identifier for the subsection of the plan", "definition": "Identifies a sub-style or sub-collective of coverage issued by the underwriter, for example may be used to identify a subset of a collection of benefits provided to employees.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "IN1-10" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.subPlanDisplay", "short": "Display text for the subsection of the plan", "definition": "A short description for the subplan.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "IN1-10" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.class", "short": "An identifier for the class", "definition": "Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage such as a level of deductables or co-payment.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "cdanetv4", "map": "C01" }, { "identity": "v2", "map": "IN1-35" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.classDisplay", "short": "Display text for the class", "definition": "A short description for the class.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "cdanetv4", "map": "C01" }, { "identity": "v2", "map": "IN1-35" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.subClass", "short": "An identifier for the subsection of the class", "definition": "Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a subclass of coverage such as a sub-level of deductables or co-payment.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "cdanetv4", "map": "C01" }, { "identity": "v2", "map": "IN1-35" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.subClassDisplay", "short": "Display text for the subsection of the subclass", "definition": "A short description for the subclass.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "cdanetv4", "map": "C01" }, { "identity": "v2", "map": "IN1-35" } ] }, { "id": "Coverage.string", "path": "Coverage.dependent", "short": "Dependent number", "definition": "A unique identifier for a dependent under the coverage.", "comment": "Note that FHIR strings may not exceed 1MB in size", "requirements": "For some coverage a single identifier is issued to the Subscriber and a dependent number issued to each beneficiary.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "cdanetv4", "map": "C17" }, { "identity": "v2", "map": "- No exact HL7 v2 equivalent concept seems to exist;" } ] }, { "id": "Coverage.string", "path": "Coverage.sequence", "short": "The plan instance or sequence counter", "definition": "An optional counter for a particular instance of the identified coverage which increments upon each renewal.", "comment": "Note that FHIR strings may not exceed 1MB in size", "requirements": "Some coverage, for example social plans, may be offered in short time increments, for example for a week or a month at a time, so while the rest of the plan details and identifiers may remain constant over time, the instance is incremented with each renewal and provided to the covered party on their 'card'.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "cdanetv4", "map": "D11" }, { "identity": "v2", "map": "No HL7 v2 equivalent concept seems to exist" } ] }, { "id": "Coverage.positiveInt", "path": "Coverage.order", "short": "Relative order of the coverage", "definition": "The order of applicability of this coverage relative to other coverages which are currently inforce. Note, there may be gaps in the numbering and this does not imply primary, secondard etc. as the specific positioning of coverages depends upon the episode of care.", "comment": "32 bit number; for values larger than this, use decimal", "min": 0, "max": "1", "type": [ { "code": "positiveInt" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "- No exact HL7 v2 equivalent concept seems to exist;" } ] }, { "id": "Coverage.string", "path": "Coverage.network", "short": "Insurer network", "definition": "The 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.", "comment": "Note that FHIR strings may not exceed 1MB in size", "min": 0, "max": "1", "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "cdanetv4", "map": "D10" } ] }, { "id": "Coverage.Reference", "path": "Coverage.contract", "short": "Contract details", "definition": "The policy(s) which constitute this insurance coverage.", "comment": "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.", "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Contract" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "cdanetv4", "map": "D01 through D09" }, { "identity": "v2", "map": "IN1-16, 18, 19" }, { "identity": "cpha3pharm", "map": "C.35" } ] } ] }, "differential": { "element": [ { "id": "Coverage", "path": "Coverage", "short": "Insurance or medical plan or a payment agreement", "definition": "Financial instrument which may be used to reimburse or pay for health care products and services.", "mapping": [ { "identity": "workflow", "map": "Event" }, { "identity": "rim", "map": "Coverage" }, { "identity": "w5", "map": "financial.support" } ] }, { "id": "Coverage.Identifier", "path": "Coverage.identifier", "short": "The primary coverage ID", "definition": "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 concatination of the Coverage.SubscriberID and the Coverage.dependant.", "comment": "This data element is supported but it's optional.", "requirements": "This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below.", "type": [ { "code": "Identifier" } ], "mapping": [ { "identity": "workflow", "map": "Event.identifier" }, { "identity": "cdanetv4", "map": "C02" }, { "identity": "v2", "map": "IN1-2" }, { "identity": "cpha3pharm", "map": "C.32, C.33, C.39" }, { "identity": "w5", "map": "id" } ] }, { "id": "Coverage.code", "path": "Coverage.status", "short": "active | cancelled | draft | entered-in-error", "definition": "The status of the resource instance. User selected status.", "comment": "This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "mustSupport": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "CoverageStatus" } ], "strength": "required", "description": "A code specifying the state of the resource instance.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/fm-status" } }, "mapping": [ { "identity": "workflow", "map": "Event.status" }, { "identity": "w5", "map": "status" } ] }, { "id": "Coverage.CodeableConcept", "path": "Coverage.type", "short": "Type of coverage such as medical or accident", "definition": "The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization. For now will use the list from FHIR. However, this is very long list and not very intuitive. We may consider using a smaller subset after following up with SMEs.", "requirements": "The order of application of coverages is dependent on the types of coverage.", "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "CoverageType" } ], "strength": "preferred", "description": "The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/coverage-type" } }, "mapping": [ { "identity": "v2", "map": "IN1-15" }, { "identity": "w5", "map": "class" } ] }, { "id": "Coverage.Reference", "path": "Coverage.Reference", "short": "Owner of the policy", "definition": "The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer.This may be needed for insurance through employer but otherwise it will be same as subscriber so we can consider this at later time. It will be questionable how all employer organizations are added in OCP to make it work.", "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ocp-patient" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ocp-relatedperson" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization" } ], "mapping": [ { "identity": "cdanetv4", "map": "D01 through D09" }, { "identity": "v2", "map": "IN1-16, 18, 19-name of insured, address, date of birth" }, { "identity": "cpha3pharm", "map": "C.35" }, { "identity": "w5", "map": "who.focus" } ] }, { "id": "Coverage.Reference", "path": "Coverage.subscriber", "short": "Subscriber to the policy", "definition": "The 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. Default to Patient but user can choose related person who is the subscriber or primary insured person.", "min": 1, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ocp-patient" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ocp-relatedperson" } ], "mustSupport": true, "mapping": [ { "identity": "cdanetv4", "map": "D01 through D09" }, { "identity": "v2", "map": "IN1-16, 18, 19-name of insured, address, date of birth" }, { "identity": "cpha3pharm", "map": "C.35" }, { "identity": "w5", "map": "who.focus" } ] }, { "id": "Coverage.string", "path": "Coverage.subscriberId", "short": "ID assigned to the Subscriber", "definition": "The insurer assigned ID for the Subscriber. Subscriber identifier (e.g. insurance policy, Medicaid #, Medicare #, group policy number etc.)", "min": 1, "max": "1", "type": [ { "code": "string" } ], "mustSupport": true, "mapping": [ { "identity": "cdanetv4", "map": "D01 through D09" }, { "identity": "v2", "map": "IN1-16, 18, 19-name of insured, address, date of birth" }, { "identity": "cpha3pharm", "map": "C.35" }, { "identity": "w5", "map": "who.focus" } ] }, { "id": "Coverage.Reference", "path": "Coverage.beneficiary", "short": "Plan Beneficiary", "definition": "The party who benefits from the insurance coverage., the patient when services are provided.", "min": 1, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ocp-patient" } ], "mustSupport": true, "mapping": [ { "identity": "workflow", "map": "Event.subject" }, { "identity": "cdanetv4", "map": "D01 through D09" }, { "identity": "v2", "map": "IN1-16, 18, 19-name of insured, address, date of birth" }, { "identity": "cpha3pharm", "map": "C.35" }, { "identity": "w5", "map": "who.focus" } ] }, { "id": "Coverage.CodeableConcept", "path": "Coverage.relationship", "short": "Beneficiary relationship to the Subscriber", "definition": "The relationship of beneficiary (patient) to the subscriber. Use the list from FHIR but default to \"Self\".", "requirements": "To determine relationship between the patient and the subscriber.", "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Relationship" } ], "strength": "example", "description": "The relationship between the Policyholder and the Beneficiary (insured/covered party/patient).", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/policyholder-relationship" } }, "mapping": [ { "identity": "cdanetv4", "map": "C03" } ] }, { "id": "Coverage.Period", "path": "Coverage.period", "short": "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.", "min": 1, "max": "1", "type": [ { "code": "Period" } ], "mustSupport": true, "mapping": [ { "identity": "workflow", "map": "Event.occurrence" }, { "identity": "v2", "map": "IN1-12 / IN1-13" }, { "identity": "w5", "map": "when.done" } ] }, { "id": "Coverage.Period.start", "path": "Coverage.period.start", "definition": "The start of the period. The boundary is inclusive. Period.start is required.", "min": 1 }, { "id": "Coverage.Reference", "path": "Coverage.payor", "short": "Identifier for the plan or agreement issuer", "definition": "The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements. May provide multiple identifiers such as insurance company identifier or business identifier (BIN number).", "requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ocp-patient" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ocp-relatedperson" } ], "mapping": [ { "identity": "cdanetv4", "map": "A05" }, { "identity": "v2", "map": "IN1-3" }, { "identity": "cpha3pharm", "map": "C.30" }, { "identity": "w5", "map": "who.author" } ] }, { "id": "Coverage.BackboneElement", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Group" } ], "path": "Coverage.grouping", "short": "Additional coverage classifications", "definition": "A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan.", "max": "1", "type": [ { "code": "BackboneElement" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.group", "short": "An identifier for the group", "definition": "Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify an employer group. May also be referred to as a Policy or Group ID.", "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "cdanetv4", "map": "C11 (Division,Section)" }, { "identity": "v2", "map": "IN1-8" }, { "identity": "cpha3pharm", "map": "C.31" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.groupDisplay", "short": "Display text for an identifier for the group", "definition": "A short description for the group.", "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "cdanetv4", "map": "C11 (Division,Section)" }, { "identity": "v2", "map": "IN1-8" }, { "identity": "cpha3pharm", "map": "C.31" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.subGroup", "short": "An identifier for the subsection of the group", "definition": "Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a subset of an employer group.", "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "v2", "map": "IN1-8" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.subGroupDisplay", "short": "Display text for the subsection of the group", "definition": "A short description for the subgroup.", "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "v2", "map": "IN1-8" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.plan", "short": "An identifier for the plan", "definition": "Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a collection of benefits provided to employees. May be referred to as a Section or Division ID.", "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "cdanetv4", "map": "C01" }, { "identity": "v2", "map": "IN1-35" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.planDisplay", "short": "Display text for the plan", "definition": "A short description for the plan.", "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "cdanetv4", "map": "C01" }, { "identity": "v2", "map": "IN1-35" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.subPlan", "short": "An identifier for the subsection of the plan", "definition": "Identifies a sub-style or sub-collective of coverage issued by the underwriter, for example may be used to identify a subset of a collection of benefits provided to employees.", "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "v2", "map": "IN1-10" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.subPlanDisplay", "short": "Display text for the subsection of the plan", "definition": "A short description for the subplan.", "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "v2", "map": "IN1-10" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.class", "short": "An identifier for the class", "definition": "Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage such as a level of deductables or co-payment.", "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "cdanetv4", "map": "C01" }, { "identity": "v2", "map": "IN1-35" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.classDisplay", "short": "Display text for the class", "definition": "A short description for the class.", "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "cdanetv4", "map": "C01" }, { "identity": "v2", "map": "IN1-35" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.subClass", "short": "An identifier for the subsection of the class", "definition": "Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a subclass of coverage such as a sub-level of deductables or co-payment.", "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "cdanetv4", "map": "C01" }, { "identity": "v2", "map": "IN1-35" } ] }, { "id": "Coverage.BackboneElement.string", "path": "Coverage.grouping.subClassDisplay", "short": "Display text for the subsection of the subclass", "definition": "A short description for the subclass.", "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "cdanetv4", "map": "C01" }, { "identity": "v2", "map": "IN1-35" } ] }, { "id": "Coverage.string", "path": "Coverage.dependent", "short": "Dependent number", "definition": "A unique identifier for a dependent under the coverage.", "requirements": "For some coverage a single identifier is issued to the Subscriber and a dependent number issued to each beneficiary.", "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "cdanetv4", "map": "C17" }, { "identity": "v2", "map": "- No exact HL7 v2 equivalent concept seems to exist;" } ] }, { "id": "Coverage.string", "path": "Coverage.sequence", "short": "The plan instance or sequence counter", "definition": "An optional counter for a particular instance of the identified coverage which increments upon each renewal.", "requirements": "Some coverage, for example social plans, may be offered in short time increments, for example for a week or a month at a time, so while the rest of the plan details and identifiers may remain constant over time, the instance is incremented with each renewal and provided to the covered party on their 'card'.", "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "cdanetv4", "map": "D11" }, { "identity": "v2", "map": "No HL7 v2 equivalent concept seems to exist" } ] }, { "id": "Coverage.positiveInt", "path": "Coverage.order", "short": "Relative order of the coverage", "definition": "The order of applicability of this coverage relative to other coverages which are currently inforce. Note, there may be gaps in the numbering and this does not imply primary, secondard etc. as the specific positioning of coverages depends upon the episode of care.", "max": "1", "type": [ { "code": "positiveInt" } ], "mapping": [ { "identity": "v2", "map": "- No exact HL7 v2 equivalent concept seems to exist;" } ] }, { "id": "Coverage.string", "path": "Coverage.network", "short": "Insurer network", "definition": "The 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.", "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "cdanetv4", "map": "D10" } ] }, { "id": "Coverage.Reference", "path": "Coverage.contract", "short": "Contract details", "definition": "The policy(s) which constitute this insurance coverage.", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Contract" } ], "mapping": [ { "identity": "cdanetv4", "map": "D01 through D09" }, { "identity": "v2", "map": "IN1-16, 18, 19" }, { "identity": "cpha3pharm", "map": "C.35" } ] } ] } }