The 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. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile. The supported data elements to the OCP Coverage profile are listed below: status, type, subscriber, subscriberId, beneficiary, relationship, and period. Dependencies: Coverage profile that conforms to this specification must include reference to other resources
  • OCP-Patient
  • OCP-RelatedPerson
  • Organization (custodian, custodians, information recipients )
  • Contract
 <status value="draft" /> <date value="2017-04-19T07:44:43+10:00" /> <publisher value="SAMHSA" /> <contact> <name value="Neelima Chennamaraja, Ioana Singureanu" /> <telecom> <system value="url" /> <value value="www.eversolve.com" /> <period> <start value="1999-06-15" /> </period> </telecom> <telecom> <system value="email" /> <value value="neelima@eversolve.com" /> <use value="work" /> </telecom> <telecom> <system value="email" /> <value value="ioana@eversolve.com" /> <use value="work" /> </telecom> </contact> <description value="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. Base StructureDefinition for Coverage Resource." /> <jurisdiction> <coding> <code value="US" /> <display value="US-Realm" /> </coding> <text value="US-Realm OCP Coverage Profile published by SAMHSA" /> </jurisdiction> <purpose value="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 value="+Copyright (c) 2017 SAMHSA. All Rights Reserved." /> <fhirVersion value="3.0.1" /> <mapping> <identity value="workflow" /> <uri value="http://hl7.org/fhir/workflow" /> <name value="Workflow Mapping" /> </mapping> <mapping> <identity value="rim" /> <uri value="http://hl7.org/v3" /> <name value="RIM Mapping" /> </mapping> <mapping> <identity value="w5" /> <uri value="http://hl7.org/fhir/w5" /> <name value="W5 Mapping" /> </mapping> <mapping> <identity value="cdanetv4" /> <uri value="http://www.cda-adc.ca/en/services/cdanet/" /> <name value="Canadian Dental Association eclaims standard" /> </mapping> <mapping> <identity value="v2" /> <uri value="http://hl7.org/v2" /> <name value="HL7 v2 Mapping" /> </mapping> <mapping> <identity value="cpha3pharm" /> <uri value="http://www.pharmacists.ca/" /> <name value="Canadian Pharmacy Associaiton eclaims standard" /> </mapping> <kind value="resource" /> <abstract value="false" /> <type value="Coverage" /> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/DomainResource" /> <derivation value="specialization" /> <differential> <element id="Coverage"> <path value="Coverage" /> <short value="Insurance or medical plan or a payment agreement" /> <definition value="Financial instrument which may be used to reimburse or pay for health care products and services." /> <mapping> <identity value="workflow" /> <map value="Event" /> </mapping> <mapping> <identity value="rim" /> <map value="Coverage" /> </mapping> <mapping> <identity value="w5" /> <map value="financial.support" /> </mapping> </element> <element id="Coverage.Identifier"> <path value="Coverage.identifier" /> <short value="The primary coverage ID" /> <definition value="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 value="This data element is supported but it's optional." /> <requirements value="This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below." /> <type> <code value="Identifier" /> </type> <mapping> <identity value="workflow" /> <map value="Event.identifier" /> </mapping> <mapping> <identity value="cdanetv4" /> <map value="C02" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-2" /> </mapping> <mapping> <identity value="cpha3pharm" /> <map value="C.32, C.33, C.39" /> </mapping> <mapping> <identity value="w5" /> <map value="id" /> </mapping> </element> <element id="Coverage.code"> <path value="Coverage.status" /> <short value="active | cancelled | draft | entered-in-error" /> <definition value="The status of the resource instance. User selected status." /> <comment value="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 value="1" /> <max value="1" /> <type> <code value="code" /> </type> <mustSupport value="true" /> <binding> <extension url="http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName"> <valueString value="CoverageStatus" /> </extension> <strength value="required" /> <description value="A code specifying the state of the resource instance." /> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/fm-status" /> </valueSetReference> </binding> <mapping> <identity value="workflow" /> <map value="Event.status" /> </mapping> <mapping> <identity value="w5" /> <map value="status" /> </mapping> </element> <element id="Coverage.CodeableConcept"> <path value="Coverage.type" /> <short value="Type of coverage such as medical or accident" /> <definition value="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 value="The order of application of coverages is dependent on the types of coverage." /> <min value="1" /> <max value="1" /> <type> <code value="CodeableConcept" /> </type> <mustSupport value="true" /> <binding> <extension url="http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName"> <valueString value="CoverageType" /> </extension> <strength value="preferred" /> <description value="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 value="http://hl7.org/fhir/ValueSet/coverage-type" /> </valueSetReference> </binding> <mapping> <identity value="v2" /> <map value="IN1-15" /> </mapping> <mapping> <identity value="w5" /> <map value="class" /> </mapping> </element> <element id="Coverage.Reference"> <path value="Coverage.Reference" /> <short value="Owner of the policy" /> <definition value="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 value="1" /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/ocp-patient" /> </type> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/ocp-relatedperson" /> </type> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Organization" /> </type> <mapping> <identity value="cdanetv4" /> <map value="D01 through D09" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-16, 18, 19-name of insured, address, date of birth" /> </mapping> <mapping> <identity value="cpha3pharm" /> <map value="C.35" /> </mapping> <mapping> <identity value="w5" /> <map value="who.focus" /> </mapping> </element> <element id="Coverage.Reference"> <path value="Coverage.subscriber" /> <short value="Subscriber to the policy" /> <definition value="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 value="1" /> <max value="1" /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/ocp-patient" /> </type> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/ocp-relatedperson" /> </type> <mustSupport value="true" /> <mapping> <identity value="cdanetv4" /> <map value="D01 through D09" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-16, 18, 19-name of insured, address, date of birth" /> </mapping> <mapping> <identity value="cpha3pharm" /> <map value="C.35" /> </mapping> <mapping> <identity value="w5" /> <map value="who.focus" /> </mapping> </element> <element id="Coverage.string"> <path value="Coverage.subscriberId" /> <short value="ID assigned to the Subscriber" /> <definition value="The insurer assigned ID for the Subscriber. Subscriber identifier (e.g. insurance policy, Medicaid #, Medicare #, group policy number etc.)" /> <min value="1" /> <max value="1" /> <type> <code value="string" /> </type> <mustSupport value="true" /> <mapping> <identity value="cdanetv4" /> <map value="D01 through D09" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-16, 18, 19-name of insured, address, date of birth" /> </mapping> <mapping> <identity value="cpha3pharm" /> <map value="C.35" /> </mapping> <mapping> <identity value="w5" /> <map value="who.focus" /> </mapping> </element> <element id="Coverage.Reference"> <path value="Coverage.beneficiary" /> <short value="Plan Beneficiary" /> <definition value="The party who benefits from the insurance coverage., the patient when services are provided." /> <min value="1" /> <max value="1" /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/ocp-patient" /> </type> <mustSupport value="true" /> <mapping> <identity value="workflow" /> <map value="Event.subject" /> </mapping> <mapping> <identity value="cdanetv4" /> <map value="D01 through D09" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-16, 18, 19-name of insured, address, date of birth" /> </mapping> <mapping> <identity value="cpha3pharm" /> <map value="C.35" /> </mapping> <mapping> <identity value="w5" /> <map value="who.focus" /> </mapping> </element> <element id="Coverage.CodeableConcept"> <path value="Coverage.relationship" /> <short value="Beneficiary relationship to the Subscriber" /> <definition value="The relationship of beneficiary (patient) to the subscriber. Use the list from FHIR but default to "Self"." /> <requirements value="To determine relationship between the patient and the subscriber." /> <min value="1" /> <max value="1" /> <type> <code value="CodeableConcept" /> </type> <mustSupport value="true" /> <binding> <extension url="http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName"> <valueString value="Relationship" /> </extension> <strength value="example" /> <description value="The relationship between the Policyholder and the Beneficiary (insured/covered party/patient)." /> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/policyholder-relationship" /> </valueSetReference> </binding> <mapping> <identity value="cdanetv4" /> <map value="C03" /> </mapping> </element> <element id="Coverage.Period"> <path value="Coverage.period" /> <short value="Coverage start and end dates" /> <definition value="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 value="1" /> <max value="1" /> <type> <code value="Period" /> </type> <mustSupport value="true" /> <mapping> <identity value="workflow" /> <map value="Event.occurrence" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-12 / IN1-13" /> </mapping> <mapping> <identity value="w5" /> <map value="when.done" /> </mapping> </element> <element id="Coverage.Period.start"> <path value="Coverage.period.start" /> <definition value="The start of the period. The boundary is inclusive. Period.start is required." /> <min value="1" /> </element> <element id="Coverage.Reference"> <path value="Coverage.payor" /> <short value="Identifier for the plan or agreement issuer" /> <definition value="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 value="Need to identify the issuer to target for processing and for coordination of benefit processing." /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Organization" /> </type> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/ocp-patient" /> </type> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/ocp-relatedperson" /> </type> <mapping> <identity value="cdanetv4" /> <map value="A05" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-3" /> </mapping> <mapping> <identity value="cpha3pharm" /> <map value="C.30" /> </mapping> <mapping> <identity value="w5" /> <map value="who.author" /> </mapping> </element> <element id="Coverage.BackboneElement"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Group" /> </extension> <path value="Coverage.grouping" /> <short value="Additional coverage classifications" /> <definition value="A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan." /> <max value="1" /> <type> <code value="BackboneElement" /> </type> </element> <element id="Coverage.BackboneElement.string"> <path value="Coverage.grouping.group" /> <short value="An identifier for the group" /> <definition value="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 value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="cdanetv4" /> <map value="C11 (Division,Section)" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-8" /> </mapping> <mapping> <identity value="cpha3pharm" /> <map value="C.31" /> </mapping> </element> <element id="Coverage.BackboneElement.string"> <path value="Coverage.grouping.groupDisplay" /> <short value="Display text for an identifier for the group" /> <definition value="A short description for the group." /> <max value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="cdanetv4" /> <map value="C11 (Division,Section)" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-8" /> </mapping> <mapping> <identity value="cpha3pharm" /> <map value="C.31" /> </mapping> </element> <element id="Coverage.BackboneElement.string"> <path value="Coverage.grouping.subGroup" /> <short value="An identifier for the subsection of the group" /> <definition value="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 value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="v2" /> <map value="IN1-8" /> </mapping> </element> <element id="Coverage.BackboneElement.string"> <path value="Coverage.grouping.subGroupDisplay" /> <short value="Display text for the subsection of the group" /> <definition value="A short description for the subgroup." /> <max value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="v2" /> <map value="IN1-8" /> </mapping> </element> <element id="Coverage.BackboneElement.string"> <path value="Coverage.grouping.plan" /> <short value="An identifier for the plan" /> <definition value="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 value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="cdanetv4" /> <map value="C01" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-35" /> </mapping> </element> <element id="Coverage.BackboneElement.string"> <path value="Coverage.grouping.planDisplay" /> <short value="Display text for the plan" /> <definition value="A short description for the plan." /> <max value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="cdanetv4" /> <map value="C01" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-35" /> </mapping> </element> <element id="Coverage.BackboneElement.string"> <path value="Coverage.grouping.subPlan" /> <short value="An identifier for the subsection of the plan" /> <definition value="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 value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="v2" /> <map value="IN1-10" /> </mapping> </element> <element id="Coverage.BackboneElement.string"> <path value="Coverage.grouping.subPlanDisplay" /> <short value="Display text for the subsection of the plan" /> <definition value="A short description for the subplan." /> <max value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="v2" /> <map value="IN1-10" /> </mapping> </element> <element id="Coverage.BackboneElement.string"> <path value="Coverage.grouping.class" /> <short value="An identifier for the class" /> <definition value="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 value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="cdanetv4" /> <map value="C01" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-35" /> </mapping> </element> <element id="Coverage.BackboneElement.string"> <path value="Coverage.grouping.classDisplay" /> <short value="Display text for the class" /> <definition value="A short description for the class." /> <max value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="cdanetv4" /> <map value="C01" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-35" /> </mapping> </element> <element id="Coverage.BackboneElement.string"> <path value="Coverage.grouping.subClass" /> <short value="An identifier for the subsection of the class" /> <definition value="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 value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="cdanetv4" /> <map value="C01" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-35" /> </mapping> </element> <element id="Coverage.BackboneElement.string"> <path value="Coverage.grouping.subClassDisplay" /> <short value="Display text for the subsection of the subclass" /> <definition value="A short description for the subclass." /> <max value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="cdanetv4" /> <map value="C01" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-35" /> </mapping> </element> <element id="Coverage.string"> <path value="Coverage.dependent" /> <short value="Dependent number" /> <definition value="A unique identifier for a dependent under the coverage." /> <requirements value="For some coverage a single identifier is issued to the Subscriber and a dependent number issued to each beneficiary." /> <max value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="cdanetv4" /> <map value="C17" /> </mapping> <mapping> <identity value="v2" /> <map value="- No exact HL7 v2 equivalent concept seems to exist;" /> </mapping> </element> <element id="Coverage.string"> <path value="Coverage.sequence" /> <short value="The plan instance or sequence counter" /> <definition value="An optional counter for a particular instance of the identified coverage which increments upon each renewal." /> <requirements value="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 value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="cdanetv4" /> <map value="D11" /> </mapping> <mapping> <identity value="v2" /> <map value="No HL7 v2 equivalent concept seems to exist" /> </mapping> </element> <element id="Coverage.positiveInt"> <path value="Coverage.order" /> <short value="Relative order of the coverage" /> <definition value="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 value="1" /> <type> <code value="positiveInt" /> </type> <mapping> <identity value="v2" /> <map value="- No exact HL7 v2 equivalent concept seems to exist;" /> </mapping> </element> <element id="Coverage.string"> <path value="Coverage.network" /> <short value="Insurer network" /> <definition value="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 value="1" /> <type> <code value="string" /> </type> <mapping> <identity value="cdanetv4" /> <map value="D10" /> </mapping> </element> <element id="Coverage.Reference"> <path value="Coverage.contract" /> <short value="Contract details" /> <definition value="The policy(s) which constitute this insurance coverage." /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Contract" /> </type> <mapping> <identity value="cdanetv4" /> <map value="D01 through D09" /> </mapping> <mapping> <identity value="v2" /> <map value="IN1-16, 18, 19" /> </mapping> <mapping> <identity value="cpha3pharm" /> <map value="C.35" /> </mapping> </element> </differential> </StructureDefinition>