haau3 FHIR Implementation Guide (HFIG)
1.0.0 - ci-build
haau3 FHIR Implementation Guide (HFIG)
1.0.0 - ci-build
haau3 FHIR Implementation Guide (HFIG) - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: https://haau3.com/fhir/StructureDefinition/haau3-coverage | Version: 1.0.0 | |||
| Draft as of 2026-10-14 | Computable Name: Haau3Coverage | |||
An insurance plan delivered for a care recipient. Every delivered record names the person it covers, says how they relate to the subscriber or states plainly that the relationship is unknown, and names a payer. Where a source system named more than one payer, the additional payers are delivered on the same record rather than dropped.
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:  |
|---|---|---|---|---|
  Coverage |
C | 0..* | USCoreCoverageProfile(6.1.0) | Insurance or medical plan or a payment agreement Constraints: us-core-15 |
  implicitRules |
0..1 | uri | A set of rules under which this content was created | |
  Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
   extension:additionalPayor |
0..* | Reference() | haau3 Additional Payor URL: https://haau3.com/fhir/StructureDefinition/haau3-additional-payor | |
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
 Slices for identifier |
0..* | Identifier | (USCDI) Member ID and other identifiers Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
 identifier:memberid |
C | 0..1 | Identifier | (USCDI) Member ID |
  use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |
  type |
1..1 | CodeableConcept | (USCDI) Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
 coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |
| display |
0..1 | string | Representation defined by the system | |
 userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| status |
1..1 | code | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | |
| type |
0..1 | CodeableConcept | (USCDI) Coverage category such as medical or accident Binding: Payer Type  (extensible): US Public Health Data Consortium Source of Payment Codes | |
| subscriberId |
C | 0..1 | string | (USCDI) ID assigned to the subscriber |
 beneficiary |
1..1 | Reference(US Core Patient Profile) | (USCDI) Plan beneficiary | |
| relationship |
1..1 | CodeableConcept | (USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) | |
| period |
0..1 | Period | (USCDI) Coverage start and end dates | |
| payor |
1..1 | Reference(US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile) | (USCDI) Issuer of the policy | |
 Slices for class |
0..* | BackboneElement | (USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
  class:All Slices |
Content/Rules for all slices | |||
  modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| type |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. | |
| value |
1..1 | string | Value associated with the type | |
| class:group |
0..1 | BackboneElement | (USCDI) Group | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
 type |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following | |
 id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| value |
1..1 | string | (USCDI) Group Number | |
 name |
0..1 | string | (USCDI) Group Name | |
| class:plan |
0..1 | BackboneElement | (USCDI) Plan | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| type |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| value |
1..1 | string | (USCDI) Plan Number | |
| name |
0..1 | string | (USCDI) Plan Name | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Coverage.identifier:memberid.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| Coverage.identifier:memberid.type | Base | extensible | IdentifierType | 📦4.0.1 | FHIR Std. |
| Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std. |
| Coverage.type | Base | extensible |
Payer Type
|
📦20221118 | VSAC v0.11 |
| Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦4.0.1 | FHIR Std. |
| Coverage.class.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std. |
| Coverage.class:group.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std. |
| Coverage.class:plan.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present |
identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()
|
This structure is derived from USCoreCoverageProfile
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Coverage |
0..* | USCoreCoverageProfile(6.1.0) | Insurance or medical plan or a payment agreement | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| extension:additionalPayor |
0..* | Reference() | haau3 Additional Payor URL: https://haau3.com/fhir/StructureDefinition/haau3-additional-payor | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| Coverage |
C | 0..* | USCoreCoverageProfile(6.1.0) | Insurance or medical plan or a payment agreement Constraints: us-core-15 | ||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| extension:additionalPayor |
0..* | Reference() | haau3 Additional Payor URL: https://haau3.com/fhir/StructureDefinition/haau3-additional-payor | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| Slices for identifier |
0..* | Identifier | (USCDI) Member ID and other identifiers Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| identifier:memberid |
C | 0..1 | Identifier | (USCDI) Member ID | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
| type |
1..1 | CodeableConcept | (USCDI) Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| system |
0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | |||||
| value |
0..1 | string | The value that is unique Example General: 123456 | |||||
| period |
0..1 | Period | Time period when id is/was valid for use | |||||
| assigner |
0..1 | Reference(Organization) | Organization that issued id (may be just text) | |||||
| status |
1..1 | code | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | |||||
| type |
0..1 | CodeableConcept | (USCDI) Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes | |||||
| policyHolder |
0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | |||||
| subscriber |
0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | |||||
| subscriberId |
C | 0..1 | string | (USCDI) ID assigned to the subscriber | ||||
| beneficiary |
1..1 | Reference(US Core Patient Profile) | (USCDI) Plan beneficiary | |||||
| dependent |
0..1 | string | Dependent number | |||||
| relationship |
1..1 | CodeableConcept | (USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) | |||||
| period |
0..1 | Period | (USCDI) Coverage start and end dates | |||||
| payor |
1..1 | Reference(US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile) | (USCDI) Issuer of the policy | |||||
| Slices for class |
0..* | BackboneElement | (USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| class:All Slices |
Content/Rules for all slices | |||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. | |||||
| value |
1..1 | string | Value associated with the type | |||||
| name |
0..1 | string | Human readable description of the type and value | |||||
| class:group |
0..1 | BackboneElement | (USCDI) Group | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| value |
1..1 | string | (USCDI) Group Number | |||||
| name |
0..1 | string | (USCDI) Group Name | |||||
| class:plan |
0..1 | BackboneElement | (USCDI) Plan | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| value |
1..1 | string | (USCDI) Plan Number | |||||
| name |
0..1 | string | (USCDI) Plan Name | |||||
| order |
0..1 | positiveInt | Relative order of the coverage | |||||
| network |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified. | |||||
 value[x] |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
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 |
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 | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| Coverage.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std. |
| Coverage.identifier:memberid.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| Coverage.identifier:memberid.type | Base | extensible | IdentifierType | 📦4.0.1 | FHIR Std. |
| Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std. |
| Coverage.type | Base | extensible |
Payer Type
|
📦20221118 | VSAC v0.11 |
| Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦4.0.1 | FHIR Std. |
| Coverage.class.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std. |
| Coverage.class:group.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std. |
| Coverage.class:plan.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std. |
| Coverage.costToBeneficiary.type | Base | extensible | Coverage Copay Type Codes | 📦4.0.1 | FHIR Std. |
| Coverage.costToBeneficiary.exception.type | Base | example | Example Coverage Financial Exception Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present |
identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()
|
This structure is derived from USCoreCoverageProfile
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Coverage |
C | 0..* | USCoreCoverageProfile(6.1.0) | Insurance or medical plan or a payment agreement Constraints: us-core-15 |
| implicitRules |
0..1 | uri | A set of rules under which this content was created | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| extension:additionalPayor |
0..* | Reference() | haau3 Additional Payor URL: https://haau3.com/fhir/StructureDefinition/haau3-additional-payor | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
| Slices for identifier |
0..* | Identifier | (USCDI) Member ID and other identifiers Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| identifier:memberid |
C | 0..1 | Identifier | (USCDI) Member ID |
| use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |
| type |
1..1 | CodeableConcept | (USCDI) Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| status |
1..1 | code | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | |
| type |
0..1 | CodeableConcept | (USCDI) Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes | |
| subscriberId |
C | 0..1 | string | (USCDI) ID assigned to the subscriber |
| beneficiary |
1..1 | Reference(US Core Patient Profile) | (USCDI) Plan beneficiary | |
| relationship |
1..1 | CodeableConcept | (USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) | |
| period |
0..1 | Period | (USCDI) Coverage start and end dates | |
| payor |
1..1 | Reference(US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile) | (USCDI) Issuer of the policy | |
| Slices for class |
0..* | BackboneElement | (USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| class:All Slices |
Content/Rules for all slices | |||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| type |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. | |
| value |
1..1 | string | Value associated with the type | |
| class:group |
0..1 | BackboneElement | (USCDI) Group | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| type |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| value |
1..1 | string | (USCDI) Group Number | |
| name |
0..1 | string | (USCDI) Group Name | |
| class:plan |
0..1 | BackboneElement | (USCDI) Plan | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| type |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| value |
1..1 | string | (USCDI) Plan Number | |
| name |
0..1 | string | (USCDI) Plan Name | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Coverage.identifier:memberid.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| Coverage.identifier:memberid.type | Base | extensible | IdentifierType | 📦4.0.1 | FHIR Std. |
| Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std. |
| Coverage.type | Base | extensible |
Payer Type
|
📦20221118 | VSAC v0.11 |
| Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦4.0.1 | FHIR Std. |
| Coverage.class.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std. |
| Coverage.class:group.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std. |
| Coverage.class:plan.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present |
identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()
|
Differential View
This structure is derived from USCoreCoverageProfile
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Coverage |
0..* | USCoreCoverageProfile(6.1.0) | Insurance or medical plan or a payment agreement | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| extension:additionalPayor |
0..* | Reference() | haau3 Additional Payor URL: https://haau3.com/fhir/StructureDefinition/haau3-additional-payor | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| Coverage |
C | 0..* | USCoreCoverageProfile(6.1.0) | Insurance or medical plan or a payment agreement Constraints: us-core-15 | ||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| extension:additionalPayor |
0..* | Reference() | haau3 Additional Payor URL: https://haau3.com/fhir/StructureDefinition/haau3-additional-payor | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| Slices for identifier |
0..* | Identifier | (USCDI) Member ID and other identifiers Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| identifier:memberid |
C | 0..1 | Identifier | (USCDI) Member ID | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
| type |
1..1 | CodeableConcept | (USCDI) Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| system |
0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | |||||
| value |
0..1 | string | The value that is unique Example General: 123456 | |||||
| period |
0..1 | Period | Time period when id is/was valid for use | |||||
| assigner |
0..1 | Reference(Organization) | Organization that issued id (may be just text) | |||||
| status |
1..1 | code | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | |||||
| type |
0..1 | CodeableConcept | (USCDI) Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes | |||||
| policyHolder |
0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | |||||
| subscriber |
0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | |||||
| subscriberId |
C | 0..1 | string | (USCDI) ID assigned to the subscriber | ||||
| beneficiary |
1..1 | Reference(US Core Patient Profile) | (USCDI) Plan beneficiary | |||||
| dependent |
0..1 | string | Dependent number | |||||
| relationship |
1..1 | CodeableConcept | (USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) | |||||
| period |
0..1 | Period | (USCDI) Coverage start and end dates | |||||
| payor |
1..1 | Reference(US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile) | (USCDI) Issuer of the policy | |||||
| Slices for class |
0..* | BackboneElement | (USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| class:All Slices |
Content/Rules for all slices | |||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. | |||||
| value |
1..1 | string | Value associated with the type | |||||
| name |
0..1 | string | Human readable description of the type and value | |||||
| class:group |
0..1 | BackboneElement | (USCDI) Group | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| value |
1..1 | string | (USCDI) Group Number | |||||
| name |
0..1 | string | (USCDI) Group Name | |||||
| class:plan |
0..1 | BackboneElement | (USCDI) Plan | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| value |
1..1 | string | (USCDI) Plan Number | |||||
| name |
0..1 | string | (USCDI) Plan Name | |||||
| order |
0..1 | positiveInt | Relative order of the coverage | |||||
| network |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified. | |||||
| value[x] |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
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 |
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 | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| Coverage.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std. |
| Coverage.identifier:memberid.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| Coverage.identifier:memberid.type | Base | extensible | IdentifierType | 📦4.0.1 | FHIR Std. |
| Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std. |
| Coverage.type | Base | extensible |
Payer Type
|
📦20221118 | VSAC v0.11 |
| Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦4.0.1 | FHIR Std. |
| Coverage.class.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std. |
| Coverage.class:group.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std. |
| Coverage.class:plan.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std. |
| Coverage.costToBeneficiary.type | Base | extensible | Coverage Copay Type Codes | 📦4.0.1 | FHIR Std. |
| Coverage.costToBeneficiary.exception.type | Base | example | Example Coverage Financial Exception Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present |
identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()
|
This structure is derived from USCoreCoverageProfile
Other representations of profile: CSV, Excel, Schematron