Standard Health Record

CoverageProfile

Definitions for shr-financial-Coverage.

Coverage
Definition

Health insurance coverage available (even if not used for payment for a given encounter).

Control0..*
InvariantsDefined on this element
dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative (: contained.text.empty())
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource (: contained.where(('#'+id in %resource.descendants().reference).not()).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
Coverage.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typeid
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Coverage.meta
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.

Control0..1
TypeMeta
Coverage.implicitRules
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.

Control0..1
Typeuri
Is Modifiertrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element.

This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.

Coverage.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language.
The codes SHALL be taken from Common Languages; other codes may be used where these codes are not suitable
Typecode
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Coverage.text
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.

Control0..1 This element is affected by the following invariants: dom-1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.

Coverage.contained
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.

Control0..*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

Coverage.extension
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.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Coverage.extension ([CanonicalType[http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-SubjectOfInformation-extension]])
Definition

The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Coverage.extension ([CanonicalType[http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-SourceOfInformation-extension]])
Definition

The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Coverage.extension ([CanonicalType[http://standardhealthrecord.org/fhir/StructureDefinition/cimi-element-Annotation-extension]])
Definition

An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Annotation(AnnotationProfile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Coverage.extension ([CanonicalType[http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-RecordStatus-extension]])
Definition

Concept indicating the state of this record, e.g., 'entered in error'.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept(CodeableConceptProfile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Coverage.extension ([CanonicalType[http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Recorded-extension]])
Definition

The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Coverage.extension ([CanonicalType[http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Signed-extension]])
Definition

Provenance information specific to the signing of the clinical statement.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Coverage.extension ([CanonicalType[http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Cosigned-extension]])
Definition

Provenance information specific to the cosigning of the clinical statement.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Coverage.extension ([CanonicalType[http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Verified-extension]])
Definition

Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Coverage.modifierExtension
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.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Coverage.identifier
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.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below.

Coverage.status
Definition

The status of the resource instance.

Control0..1
BindingA code specifying the state of the resource instance.
The codes SHALL be taken from Financial Resource Status Codes
Typecode
Is Modifiertrue
Comments

This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.

Coverage.type
Definition

The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.

Control1..1
BindingThe type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.
The codes SHOULD be taken from Coverage Type and Self-Pay Codes
TypeCodeableConcept(CodeableConceptProfile)
Requirements

The order of application of coverages is dependent on the types of coverage.

Coverage.policyHolder
Definition

The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer.

Control0..1
TypeReference(PatientProfile | RelatedPersonProfile | OrganizationProfile)
Coverage.subscriber
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.

Control0..1
TypeReference(Patient | RelatedPerson)
Coverage.subscriberId
Definition

The insurer assigned ID for the Subscriber.

Control0..1
Typestring
Coverage.beneficiary
Definition

The party who benefits from the insurance coverage., the patient when services are provided.

Control0..1
TypeReference(Patient)
Coverage.relationship
Definition

The relationship of beneficiary (patient) to the subscriber.

Control0..1
BindingThe relationship between the Policyholder and the Beneficiary (insured/covered party/patient).
For example codes, see Policyholder Relationship Codes
TypeCodeableConcept
Requirements

To determine relationship between the patient and the subscriber.

Coverage.period
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.

Control0..1
TypePeriod
Coverage.payor
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).

Control0..*
TypeReference(Organization | Patient | RelatedPerson)
Requirements

Need to identify the issuer to target for processing and for coordination of benefit processing.

Coverage.grouping
Definition

A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan.

Control0..1
TypeBackboneElement
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
Coverage.grouping.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Coverage.grouping.extension
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.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Coverage.grouping.modifierExtension
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.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Coverage.grouping.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.

Control0..1
Typestring
Coverage.grouping.groupDisplay
Definition

A short description for the group.

Control0..1
Typestring
Coverage.grouping.subGroup
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.

Control0..1
Typestring
Coverage.grouping.subGroupDisplay
Definition

A short description for the subgroup.

Control0..1
Typestring
Coverage.grouping.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.

Control0..1
Typestring
Coverage.grouping.planDisplay
Definition

A short description for the plan.

Control0..1
Typestring
Coverage.grouping.subPlan
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.

Control0..1
Typestring
Coverage.grouping.subPlanDisplay
Definition

A short description for the subplan.

Control0..1
Typestring
Coverage.grouping.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.

Control0..1
Typestring
Coverage.grouping.classDisplay
Definition

A short description for the class.

Control0..1
Typestring
Coverage.grouping.subClass
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.

Control0..1
Typestring
Coverage.grouping.subClassDisplay
Definition

A short description for the subclass.

Control0..1
Typestring
Coverage.dependent
Definition

A unique identifier for a dependent under the coverage.

Control0..1
Typestring
Requirements

For some coverage a single identifier is issued to the Subscriber and a dependent number issued to each beneficiary.

Coverage.sequence
Definition

An optional counter for a particular instance of the identified coverage which increments upon each renewal.

Control0..1
Typestring
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'.

Coverage.order
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.

Control0..1
TypepositiveInt
Coverage.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.

Control0..1
Typestring
Coverage.contract
Definition

The policy(s) which constitute this insurance coverage.

Control0..*
TypeReference(Contract)