CH.FHIR.IG.CH-CORE\CH Core Coverage Profile

This page is part of the CH Core (R4) (v2.0.0: STU 2) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Resource Profile: CH Core Coverage Profile

Defining URL:

http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-coverage

Version:

2.0.0

Name:

CHCoreCoverage

Title:

CH Core Coverage Profile

Status:

Active as of 2019-05-20T00:00:00+00:00

Definition:

The Coverage referenced in the CH Core profiles.

Publisher:

HL7 Switzerland

CC-BY-SA-4.0

Source Resource:

XML / JSON / Turtle

The official URL for this profile is:

http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-coverage

Formal Views of Profile Content

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

Text Summary
Differential Table
Snapshot Table
Snapshot Table (Must Support)
All

This structure is derived from Coverage

Summary

Mandatory: 0 element (2 nested mandatory elements)
Fixed Value: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

This structure is derived from Coverage

Name	Card.	Type	Description & Constraints
Coverage	0..*	Coverage	CH Core Coverage
identifier	0..*	(Slice Definition)	Business Identifier for the coverage Slice: Unordered, Open by value:system
identifier:insurancecardnumber	0..*	Identifier	insurancecardnumber
system	1..1	uri	oid of the insurance card number Fixed Value: urn:oid:2.16.756.5.30.1.123.100.1.1.1
value	1..1	string	Insurance card number of the patient (20 digits)
policyHolder	0..1	Reference(CH Core Patient Profile \| RelatedPerson \| CH Core Organization Profile)	Owner of the policy
subscriber	0..1	Reference(CH Core Patient Profile \| RelatedPerson)	Subscriber to the policy
beneficiary	1..1	Reference(CH Core Patient Profile)	Plan beneficiary
payor	1..*	Reference(CH Core Organization Profile \| CH Core Patient Profile \| RelatedPerson)	Issuer of the policy
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	CH Core Coverage
id	Σ	0..1	string	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) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	(Slice Definition)	Business Identifier for the coverage Slice: Unordered, Open by value:system
identifier:insurancecardnumber	Σ	0..*	Identifier	insurancecardnumber
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	1..1	uri	oid of the insurance card number Fixed Value: urn:oid:2.16.756.5.30.1.123.100.1.1.1
value	Σ	1..1	string	Insurance card number of the patient (20 digits) 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)
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 Profile \| RelatedPerson \| CH Core Organization Profile)	Owner of the policy
subscriber	Σ	0..1	Reference(CH Core Patient Profile \| RelatedPerson)	Subscriber to the policy
subscriberId	Σ	0..1	string	ID assigned to the subscriber
beneficiary	Σ	1..1	Reference(CH Core Patient Profile)	Plan beneficiary
dependent	Σ	0..1	string	Dependent number
relationship		0..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
period	Σ	0..1	Period	Coverage start and end dates
payor	Σ	1..*	Reference(CH Core Organization Profile \| CH Core Patient Profile \| RelatedPerson)	Issuer of the policy
class		0..*	BackboneElement	Additional coverage classifications
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): 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

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	CH Core Coverage
Documentation for this format

This structure is derived from Coverage

Summary

Mandatory: 0 element (2 nested mandatory elements)
Fixed Value: 1 element

Structures

This structure refers to these other structures:

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	Card.	Type	Description & Constraints
Coverage	0..*	Coverage	CH Core Coverage
identifier	0..*	(Slice Definition)	Business Identifier for the coverage Slice: Unordered, Open by value:system
identifier:insurancecardnumber	0..*	Identifier	insurancecardnumber
system	1..1	uri	oid of the insurance card number Fixed Value: urn:oid:2.16.756.5.30.1.123.100.1.1.1
value	1..1	string	Insurance card number of the patient (20 digits)
policyHolder	0..1	Reference(CH Core Patient Profile \| RelatedPerson \| CH Core Organization Profile)	Owner of the policy
subscriber	0..1	Reference(CH Core Patient Profile \| RelatedPerson)	Subscriber to the policy
beneficiary	1..1	Reference(CH Core Patient Profile)	Plan beneficiary
payor	1..*	Reference(CH Core Organization Profile \| CH Core Patient Profile \| RelatedPerson)	Issuer of the policy
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	CH Core Coverage
id	Σ	0..1	string	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) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	(Slice Definition)	Business Identifier for the coverage Slice: Unordered, Open by value:system
identifier:insurancecardnumber	Σ	0..*	Identifier	insurancecardnumber
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	1..1	uri	oid of the insurance card number Fixed Value: urn:oid:2.16.756.5.30.1.123.100.1.1.1
value	Σ	1..1	string	Insurance card number of the patient (20 digits) 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)
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 Profile \| RelatedPerson \| CH Core Organization Profile)	Owner of the policy
subscriber	Σ	0..1	Reference(CH Core Patient Profile \| RelatedPerson)	Subscriber to the policy
subscriberId	Σ	0..1	string	ID assigned to the subscriber
beneficiary	Σ	1..1	Reference(CH Core Patient Profile)	Plan beneficiary
dependent	Σ	0..1	string	Dependent number
relationship		0..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
period	Σ	0..1	Period	Coverage start and end dates
payor	Σ	1..*	Reference(CH Core Organization Profile \| CH Core Patient Profile \| RelatedPerson)	Issuer of the policy
class		0..*	BackboneElement	Additional coverage classifications
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): 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

Other representations of profile: Schematron

Terminology Bindings

Path	Conformance	ValueSet
Coverage.language	preferred	CommonLanguages Max Binding: AllLanguages
Coverage.identifier:insurancecardnumber.use	required	IdentifierUse
Coverage.identifier:insurancecardnumber.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	Path	Details	Requirements
dom-2	Coverage	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	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	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	Coverage	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	Coverage	A resource should have narrative for robust management : text.`div`.exists()
ele-1	Coverage.meta	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.implicitRules	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.language	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.text	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Coverage.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Coverage.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Coverage.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Coverage.identifier	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.identifier:insurancecardnumber	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.identifier:insurancecardnumber.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Coverage.identifier:insurancecardnumber.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Coverage.identifier:insurancecardnumber.use	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.identifier:insurancecardnumber.type	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.identifier:insurancecardnumber.system	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.identifier:insurancecardnumber.value	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.identifier:insurancecardnumber.period	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.identifier:insurancecardnumber.assigner	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.status	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.type	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.policyHolder	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.subscriber	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.subscriberId	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.beneficiary	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.dependent	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.relationship	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.period	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.payor	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.class	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.class.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Coverage.class.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Coverage.class.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Coverage.class.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Coverage.class.type	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.class.value	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.class.name	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.order	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.network	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.costToBeneficiary	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.costToBeneficiary.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Coverage.costToBeneficiary.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Coverage.costToBeneficiary.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Coverage.costToBeneficiary.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Coverage.costToBeneficiary.type	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.costToBeneficiary.value[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.costToBeneficiary.exception	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.costToBeneficiary.exception.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Coverage.costToBeneficiary.exception.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Coverage.costToBeneficiary.exception.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	Coverage.costToBeneficiary.exception.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	Coverage.costToBeneficiary.exception.type	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.costToBeneficiary.exception.period	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.subrogation	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	Coverage.contract	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())