This page is part of the CH Core (R4) (v4.0.0-ballot: STU Ballot 1) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

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Resource Profile: CH Core Coverage

The Coverage referenced in the CH Core profiles.

Coverage information which can be shared

Usage:

• Examples for this Resource Profile: Coverage/CoverageBroennimann

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	CH Core Coverage
Slices for identifier		0..*	Identifier	Business Identifier for the coverage Slice: Unordered, Open by value:system
identifier:All Slices				Content/Rules for all slices
value		1..1	string	The value that is unique
identifier:insuranceCardNumber		0..*	VEKAIdentifier	Insurance card number of the patient (20 digits) Required Pattern: At least the following
system		1..1	uri	The namespace for the identifier value Fixed Value: urn:oid:2.16.756.5.30.1.123.100.1.1.1
policyHolder		0..1	Reference(CH Core Patient | RelatedPerson | CH Core Organization)	Owner of the policy
subscriber		0..1	Reference(CH Core Patient | RelatedPerson)	Subscriber to the policy
beneficiary		1..1	Reference(CH Core Patient)	Plan beneficiary
payor		1..*	Reference(CH Core Organization | CH Core Patient | RelatedPerson) {c, r}	Issuer of the policy (if it is not the patient him/herself, represent the payor as a contained resource)
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	CH Core Coverage
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
Slices for identifier	Σ	0..*	Identifier	Business Identifier for the coverage Slice: Unordered, Open by value:system
identifier:All Slices				Content/Rules for all slices
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value	Σ	1..1	string	The value that is unique Example General: 123456
identifier:insuranceCardNumber		0..*	VEKAIdentifier	Insurance card number of the patient (20 digits) Required Pattern: At least the following
system		1..1	uri	The namespace for the identifier value Fixed Value: urn:oid:2.16.756.5.30.1.123.100.1.1.1
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
policyHolder	Σ	0..1	Reference(CH Core Patient | RelatedPerson | CH Core Organization)	Owner of the policy
subscriber	Σ	0..1	Reference(CH Core Patient | RelatedPerson)	Subscriber to the policy
beneficiary	Σ	1..1	Reference(CH Core Patient)	Plan beneficiary
payor	Σ	1..*	Reference(CH Core Organization | CH Core Patient | RelatedPerson) {c, r}	Issuer of the policy (if it is not the patient him/herself, represent the payor as a contained resource)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Coverage.identifier.use	required	IdentifierUse
Coverage.status	required	FinancialResourceStatusCodes

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	CH Core Coverage
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
Slices for identifier	Σ	0..*	Identifier	Business Identifier for the coverage Slice: Unordered, Open by value:system
identifier: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 Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier 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.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
identifier:insuranceCardNumber		0..*	VEKAIdentifier	Insurance card number of the patient (20 digits) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
use		0..1	code	usual | official | temp | secondary | old (If known)
type		0..1	CodeableConcept	Description of identifier
system		1..1	uri	The namespace for the identifier value Fixed Value: urn:oid:2.16.756.5.30.1.123.100.1.1.1
value		0..1	string	The value that is unique
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	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.
policyHolder	Σ	0..1	Reference(CH Core Patient | RelatedPerson | CH Core Organization)	Owner of the policy
subscriber	Σ	0..1	Reference(CH Core Patient | RelatedPerson)	Subscriber to the policy
subscriberId	Σ	0..1	string	ID assigned to the subscriber
beneficiary	Σ	1..1	Reference(CH Core Patient)	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
payor	Σ	1..*	Reference(CH Core Organization | CH Core Patient | RelatedPerson) {c, r}	Issuer of the policy (if it is not the patient him/herself, represent the payor as a contained resource)
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): The policy classifications, eg. Group, Plan, Class, etc.
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.identifier.use	required	IdentifierUse
Coverage.identifier.type	extensible	Identifier Type Codes
Coverage.status	required	FinancialResourceStatusCodes
Coverage.type	preferred	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: 0 element (1 nested mandatory element)

Structures

This structure refers to these other structures:

• Insurance Card Number (Identifier) (http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-veka-identifier)
• CH Core Patient (http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient)
• CH Core Organization (http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-organization)

Slices

This structure defines the following Slices:

• The element Coverage.identifier is sliced based on the value of value:system

Differential View

This structure is derived from Coverage

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	CH Core Coverage
Slices for identifier		0..*	Identifier	Business Identifier for the coverage Slice: Unordered, Open by value:system
identifier:All Slices				Content/Rules for all slices
value		1..1	string	The value that is unique
identifier:insuranceCardNumber		0..*	VEKAIdentifier	Insurance card number of the patient (20 digits) Required Pattern: At least the following
system		1..1	uri	The namespace for the identifier value Fixed Value: urn:oid:2.16.756.5.30.1.123.100.1.1.1
policyHolder		0..1	Reference(CH Core Patient | RelatedPerson | CH Core Organization)	Owner of the policy
subscriber		0..1	Reference(CH Core Patient | RelatedPerson)	Subscriber to the policy
beneficiary		1..1	Reference(CH Core Patient)	Plan beneficiary
payor		1..*	Reference(CH Core Organization | CH Core Patient | RelatedPerson) {c, r}	Issuer of the policy (if it is not the patient him/herself, represent the payor as a contained resource)
Documentation for this format

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	CH Core Coverage
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
Slices for identifier	Σ	0..*	Identifier	Business Identifier for the coverage Slice: Unordered, Open by value:system
identifier:All Slices				Content/Rules for all slices
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value	Σ	1..1	string	The value that is unique Example General: 123456
identifier:insuranceCardNumber		0..*	VEKAIdentifier	Insurance card number of the patient (20 digits) Required Pattern: At least the following
system		1..1	uri	The namespace for the identifier value Fixed Value: urn:oid:2.16.756.5.30.1.123.100.1.1.1
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
policyHolder	Σ	0..1	Reference(CH Core Patient | RelatedPerson | CH Core Organization)	Owner of the policy
subscriber	Σ	0..1	Reference(CH Core Patient | RelatedPerson)	Subscriber to the policy
beneficiary	Σ	1..1	Reference(CH Core Patient)	Plan beneficiary
payor	Σ	1..*	Reference(CH Core Organization | CH Core Patient | RelatedPerson) {c, r}	Issuer of the policy (if it is not the patient him/herself, represent the payor as a contained resource)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Coverage.identifier.use	required	IdentifierUse
Coverage.status	required	FinancialResourceStatusCodes

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	CH Core Coverage
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
Slices for identifier	Σ	0..*	Identifier	Business Identifier for the coverage Slice: Unordered, Open by value:system
identifier: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 Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier 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.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
identifier:insuranceCardNumber		0..*	VEKAIdentifier	Insurance card number of the patient (20 digits) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
use		0..1	code	usual | official | temp | secondary | old (If known)
type		0..1	CodeableConcept	Description of identifier
system		1..1	uri	The namespace for the identifier value Fixed Value: urn:oid:2.16.756.5.30.1.123.100.1.1.1
value		0..1	string	The value that is unique
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	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.
policyHolder	Σ	0..1	Reference(CH Core Patient | RelatedPerson | CH Core Organization)	Owner of the policy
subscriber	Σ	0..1	Reference(CH Core Patient | RelatedPerson)	Subscriber to the policy
subscriberId	Σ	0..1	string	ID assigned to the subscriber
beneficiary	Σ	1..1	Reference(CH Core Patient)	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
payor	Σ	1..*	Reference(CH Core Organization | CH Core Patient | RelatedPerson) {c, r}	Issuer of the policy (if it is not the patient him/herself, represent the payor as a contained resource)
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): The policy classifications, eg. Group, Plan, Class, etc.
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.identifier.use	required	IdentifierUse
Coverage.identifier.type	extensible	Identifier Type Codes
Coverage.status	required	FinancialResourceStatusCodes
Coverage.type	preferred	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: 0 element (1 nested mandatory element)

Structures

This structure refers to these other structures:

• Insurance Card Number (Identifier) (http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-veka-identifier)
• CH Core Patient (http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient)
• CH Core Organization (http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-organization)

Slices

This structure defines the following Slices:

• The element Coverage.identifier is sliced based on the value of value:system

Other representations of profile: CSV, Excel, Schematron