BSeR: Bidirectional Services_eReferral - Local Development build (v2.0.0-connectathon). See the Directory of published versions

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Resource Profile: BSeR Coverage

Coverage high-level identifiers and descriptors of an insurance plan underwriting some or all of the cost of the referral services provided.

Usage:

• Refer to this Resource Profile: BSeR Referral Service Request
• Examples for this Resource Profile: Coverage/coverage-BSeR-Coverage-eve-everywoman

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from Coverage

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement
identifier		0..1	Identifier	Business Identifier for the coverage
status		1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required)
type		1..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (extensible)
subscriber		1..1	Reference(RelatedPerson)	Subscriber to the policy
beneficiary		1..1	Reference(US Core Patient Profile)	Plan beneficiary
period		0..1	Period	Coverage start and end dates
start		1..1	dateTime	Starting time with inclusive boundary
end		0..1	dateTime	End time with inclusive boundary, if not ongoing
payor		1..1	Reference(BSeR Organization)	Issuer of the policy
class		0..*	BackboneElement	Additional coverage classifications
type		1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible)
value		1..1	string	Value associated with the type
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Coverage.status	required	FinancialResourceStatusCodes
Coverage.type	extensible	CoverageTypeAndSelf-PayCodes
Coverage.class.type	extensible	CoverageClassCodes

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Business Identifier for the coverage
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required)
type	Σ	1..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (extensible)
subscriber	Σ	1..1	Reference(RelatedPerson)	Subscriber to the policy
beneficiary	Σ	1..1	Reference(US Core Patient Profile)	Plan beneficiary
period	Σ	0..1	Period	Coverage start and end dates
start	ΣC	1..1	dateTime	Starting time with inclusive boundary
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing
payor	Σ	1..1	Reference(BSeR Organization)	Issuer of the policy
class		0..*	BackboneElement	Additional coverage classifications
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible)
value	Σ	1..1	string	Value associated with the type
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Coverage.status	required	FinancialResourceStatusCodes
Coverage.type	extensible	CoverageTypeAndSelf-PayCodes
Coverage.class.type	extensible	CoverageClassCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Coverage	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Coverage	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Coverage	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Business Identifier for the coverage
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required)
type	Σ	1..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (extensible)
policyHolder	Σ	0..1	Reference(Patient | RelatedPerson | Organization)	Owner of the policy
subscriber	Σ	1..1	Reference(RelatedPerson)	Subscriber to the policy
subscriberId	Σ	0..1	string	ID assigned to the subscriber
beneficiary	Σ	1..1	Reference(US Core Patient Profile)	Plan beneficiary
dependent	Σ	0..1	string	Dependent number
relationship		0..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
period	Σ	0..1	Period	Coverage start and end dates
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	1..1	dateTime	Starting time with inclusive boundary
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing
payor	Σ	1..1	Reference(BSeR Organization)	Issuer of the policy
class		0..*	BackboneElement	Additional coverage classifications
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible)
value	Σ	1..1	string	Value associated with the type
name	Σ	0..1	string	Human readable description of the type and value
order	Σ	0..1	positiveInt	Relative order of the coverage
network	Σ	0..1	string	Insurer network
costToBeneficiary		0..*	BackboneElement	Patient payments for services/products
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	0..1	CodeableConcept	Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
value[x]	Σ	1..1		The amount or percentage due from the beneficiary
valueQuantity			Quantity(SimpleQuantity)
valueMoney			Money
exception		0..*	BackboneElement	Exceptions for patient payments
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
period	Σ	0..1	Period	The effective period of the exception
subrogation		0..1	boolean	Reimbursement to insurer
contract		0..*	Reference(Contract)	Contract details
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Coverage.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Coverage.status	required	FinancialResourceStatusCodes
Coverage.type	extensible	CoverageTypeAndSelf-PayCodes
Coverage.relationship	extensible	SubscriberRelationshipCodes
Coverage.class.type	extensible	CoverageClassCodes
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from Coverage

Summary

Mandatory: 5 elements (3 nested mandatory elements)

Structures

This structure refers to these other structures:

• US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient)
• BSeR Organization (http://hl7.org/fhir/us/bser/StructureDefinition/BSeR-Organization)

Differential View

This structure is derived from Coverage

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement
identifier		0..1	Identifier	Business Identifier for the coverage
status		1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required)
type		1..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (extensible)
subscriber		1..1	Reference(RelatedPerson)	Subscriber to the policy
beneficiary		1..1	Reference(US Core Patient Profile)	Plan beneficiary
period		0..1	Period	Coverage start and end dates
start		1..1	dateTime	Starting time with inclusive boundary
end		0..1	dateTime	End time with inclusive boundary, if not ongoing
payor		1..1	Reference(BSeR Organization)	Issuer of the policy
class		0..*	BackboneElement	Additional coverage classifications
type		1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible)
value		1..1	string	Value associated with the type
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Coverage.status	required	FinancialResourceStatusCodes
Coverage.type	extensible	CoverageTypeAndSelf-PayCodes
Coverage.class.type	extensible	CoverageClassCodes

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Business Identifier for the coverage
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required)
type	Σ	1..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (extensible)
subscriber	Σ	1..1	Reference(RelatedPerson)	Subscriber to the policy
beneficiary	Σ	1..1	Reference(US Core Patient Profile)	Plan beneficiary
period	Σ	0..1	Period	Coverage start and end dates
start	ΣC	1..1	dateTime	Starting time with inclusive boundary
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing
payor	Σ	1..1	Reference(BSeR Organization)	Issuer of the policy
class		0..*	BackboneElement	Additional coverage classifications
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible)
value	Σ	1..1	string	Value associated with the type
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Coverage.status	required	FinancialResourceStatusCodes
Coverage.type	extensible	CoverageTypeAndSelf-PayCodes
Coverage.class.type	extensible	CoverageClassCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Coverage	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Coverage	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Coverage	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Business Identifier for the coverage
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required)
type	Σ	1..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (extensible)
policyHolder	Σ	0..1	Reference(Patient | RelatedPerson | Organization)	Owner of the policy
subscriber	Σ	1..1	Reference(RelatedPerson)	Subscriber to the policy
subscriberId	Σ	0..1	string	ID assigned to the subscriber
beneficiary	Σ	1..1	Reference(US Core Patient Profile)	Plan beneficiary
dependent	Σ	0..1	string	Dependent number
relationship		0..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
period	Σ	0..1	Period	Coverage start and end dates
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	1..1	dateTime	Starting time with inclusive boundary
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing
payor	Σ	1..1	Reference(BSeR Organization)	Issuer of the policy
class		0..*	BackboneElement	Additional coverage classifications
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible)
value	Σ	1..1	string	Value associated with the type
name	Σ	0..1	string	Human readable description of the type and value
order	Σ	0..1	positiveInt	Relative order of the coverage
network	Σ	0..1	string	Insurer network
costToBeneficiary		0..*	BackboneElement	Patient payments for services/products
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	0..1	CodeableConcept	Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
value[x]	Σ	1..1		The amount or percentage due from the beneficiary
valueQuantity			Quantity(SimpleQuantity)
valueMoney			Money
exception		0..*	BackboneElement	Exceptions for patient payments
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
period	Σ	0..1	Period	The effective period of the exception
subrogation		0..1	boolean	Reimbursement to insurer
contract		0..*	Reference(Contract)	Contract details
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Coverage.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Coverage.status	required	FinancialResourceStatusCodes
Coverage.type	extensible	CoverageTypeAndSelf-PayCodes
Coverage.relationship	extensible	SubscriberRelationshipCodes
Coverage.class.type	extensible	CoverageClassCodes
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from Coverage

Summary

Mandatory: 5 elements (3 nested mandatory elements)

Structures

This structure refers to these other structures:

• US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient)
• BSeR Organization (http://hl7.org/fhir/us/bser/StructureDefinition/BSeR-Organization)

Other representations of profile: CSV, Excel, Schematron