{
"description": null,
"_filename": "StructureDefinition-qicore-coverage.json",
"package_name": "hl7.fhir.us.qicore",
"date": "2016-07-15",
"derivation": "constraint",
"publisher": "Health Level Seven International (Clinical Quality Information - QICore)",
"name": "Profile qicore-coverage",
"mapping": [ {
"uri": "http://hl7.org/v3",
"name": "RIM Mapping",
"identity": "rim"
}, {
"uri": "http://hl7.org/fhir/w5",
"name": "W5 Mapping",
"identity": "w5"
}, {
"uri": "http://www.cda-adc.ca/en/services/cdanet/",
"name": "Canadian Dental Association eclaims standard",
"identity": "cdanetv4"
}, {
"uri": "http://hl7.org/v2",
"name": "HL7 v2 Mapping",
"identity": "v2"
}, {
"uri": "http://www.pharmacists.ca/",
"name": "Canadian Pharmacy Associaiton eclaims standard",
"identity": "cpha3pharm"
} ],
"abstract": false,
"type": "Coverage",
"experimental": null,
"resourceType": "StructureDefinition",
"title": null,
"package_version": "1.6.0",
"snapshot": {
"element": [ {
"constraint": [ {
"key": "dom-2",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"xpath": "not(parent::f:contained and f:contained)",
"severity": "error",
"expression": "contained.contained.empty()"
}, {
"key": "dom-1",
"human": "If the resource is contained in another resource, it SHALL NOT contain any narrative",
"xpath": "not(parent::f:contained and f:text)",
"severity": "error",
"expression": "contained.text.empty()"
}, {
"key": "dom-4",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"severity": "error",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()"
}, {
"key": "dom-3",
"human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource",
"xpath": "not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))",
"severity": "error",
"expression": "contained.where(('#'+id in %resource.descendants().reference).not()).empty()"
} ],
"path": "Coverage",
"min": 0,
"definition": "Financial instrument which may be used to pay for or reimburse health care products and services.",
"short": "Insurance or medical plan or a payment agreement",
"name": "QICore-Coverage",
"mapping": [ {
"map": "Entity. Role, or Act",
"identity": "rim"
}, {
"map": "Coverage",
"identity": "rim"
}, {
"map": "financial.support",
"identity": "w5"
} ],
"mustSupport": false,
"max": "*",
"id": "Coverage:qicore-coverage",
"base": {
"max": "*",
"min": 0,
"path": "Coverage"
},
"isSummary": false
}, {
"path": "Coverage.id",
"min": 0,
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"short": "Logical id of this artifact",
"comments": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"type": [ {
"code": "id"
} ],
"max": "1",
"id": "Coverage:qicore-coverage.id",
"base": {
"max": "*",
"min": 0,
"path": "Resource.id"
},
"isSummary": true
}, {
"path": "Coverage.meta",
"min": 0,
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.",
"short": "Metadata about the resource",
"type": [ {
"code": "Meta"
} ],
"max": "1",
"id": "Coverage:qicore-coverage.meta",
"base": {
"max": "*",
"min": 0,
"path": "Resource.meta"
},
"isSummary": true
}, {
"path": "Coverage.implicitRules",
"min": 0,
"definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.",
"isModifier": true,
"short": "A set of rules under which this content was created",
"comments": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.",
"type": [ {
"code": "uri"
} ],
"max": "1",
"id": "Coverage:qicore-coverage.implicitRules",
"base": {
"max": "*",
"min": 0,
"path": "Resource.implicitRules"
},
"isSummary": true
}, {
"path": "Coverage.language",
"min": 0,
"definition": "The base language in which the resource is written.",
"short": "Language of the resource content",
"comments": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "extensible",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
} ],
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
},
"max": "1",
"id": "Coverage:qicore-coverage.language",
"base": {
"max": "*",
"min": 0,
"path": "Resource.language"
}
}, {
"path": "Coverage.text",
"min": 0,
"definition": "A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.",
"short": "Text summary of the resource, for human interpretation",
"comments": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded in formation is added later.",
"mapping": [ {
"map": "Act.text?",
"identity": "rim"
} ],
"type": [ {
"code": "Narrative"
} ],
"alias": [ "narrative", "html", "xhtml", "display" ],
"max": "1",
"id": "Coverage:qicore-coverage.text",
"condition": [ "dom-1" ],
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.text"
}
}, {
"path": "Coverage.contained",
"min": 0,
"definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.",
"short": "Contained, inline Resources",
"comments": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Resource"
} ],
"alias": [ "inline resources", "anonymous resources", "contained resources" ],
"max": "*",
"id": "Coverage:qicore-coverage.contained",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.contained"
}
}, {
"path": "Coverage.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"short": "Additional Content defined by implementations",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Coverage:qicore-coverage.extension",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.extension"
}
}, {
"path": "Coverage.modifierExtension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Coverage:qicore-coverage.modifierExtension",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.modifierExtension"
}
}, {
"path": "Coverage.status",
"min": 1,
"definition": "The status of the resource instance.",
"isModifier": true,
"short": "active | cancelled | draft | entered-in-error",
"mapping": [ {
"map": "status",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/coverage-status"
}
},
"max": "1",
"id": "Coverage:qicore-coverage.status",
"base": {
"max": "1",
"min": 1,
"path": "Coverage.status"
},
"isSummary": true
}, {
"path": "Coverage.issuer[x]",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"definition": "The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.",
"short": "Identifier for the plan or agreement issuer",
"mapping": [ {
"map": "A05",
"identity": "cdanetv4"
}, {
"map": "IN1-3",
"identity": "v2"
}, {
"map": "C.30",
"identity": "cpha3pharm"
}, {
"map": "who.author",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"profile": "http://hl7.org/fhir/qicore/StructureDefinition/qicore-patient"
}, {
"code": "Reference",
"profile": "http://hl7.org/fhir/qicore/StructureDefinition/qicore-organization"
}, {
"code": "Reference",
"profile": "http://hl7.org/fhir/qicore/StructureDefinition/qicore-relatedperson"
} ],
"mustSupport": true,
"max": "1",
"id": "Coverage:qicore-coverage.issuer[x]",
"base": {
"max": "1",
"min": 1,
"path": "Coverage.issuer[x]"
},
"isSummary": false
}, {
"path": "Coverage.isAgreement",
"requirements": "Only insurance policies receive Claims, agreements receive bills.",
"min": 0,
"definition": "A self, or other, payment agreement not an insurance policy.",
"short": "Is a Payment Agreement",
"type": [ {
"code": "boolean"
} ],
"max": "1",
"id": "Coverage:qicore-coverage.isAgreement",
"base": {
"max": "1",
"min": 0,
"path": "Coverage.isAgreement"
},
"isSummary": true
}, {
"path": "Coverage.bin",
"min": 0,
"definition": "Business Identification Number (BIN number) used to identify the routing of eClaims.",
"short": "BIN Number",
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Coverage:qicore-coverage.bin",
"base": {
"max": "1",
"min": 0,
"path": "Coverage.bin"
},
"isSummary": true
}, {
"path": "Coverage.period",
"min": 0,
"definition": "Time period during which the coverage is in force. A missing start date indicates the start date isn't known, a missing end date means the coverage is continuing to be in force.",
"short": "Coverage start and end dates",
"mapping": [ {
"map": "IN1-12 / IN1-13",
"identity": "v2"
}, {
"map": "when.done",
"identity": "w5"
} ],
"type": [ {
"code": "Period"
} ],
"max": "1",
"id": "Coverage:qicore-coverage.period",
"base": {
"max": "1",
"min": 0,
"path": "Coverage.period"
},
"isSummary": true
}, {
"path": "Coverage.type",
"requirements": "The order of application of coverages is dependent on the types of coverage.",
"min": 0,
"definition": "The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health.",
"short": "Type of coverage",
"mapping": [ {
"map": "IN1-15",
"identity": "v2"
}, {
"map": "class",
"identity": "w5"
} ],
"type": [ {
"code": "Coding"
} ],
"binding": {
"strength": "example",
"description": "The type of insurance: public health, worker compensation; private accident, auto, private health, etc.).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActCoverageTypeCode"
}
},
"max": "1",
"id": "Coverage:qicore-coverage.type",
"base": {
"max": "1",
"min": 0,
"path": "Coverage.type"
},
"isSummary": true
}, {
"path": "Coverage.planholder[x]",
"min": 1,
"definition": "The party who 'owns' the insurance contractual relationship to the policy or to whom the benefit of the policy is due.",
"short": "Plan holder",
"mapping": [ {
"map": "D01 through D09",
"identity": "cdanetv4"
}, {
"map": "IN1-16, 18, 19-name of insured, address, date of birth",
"identity": "v2"
}, {
"map": "C.35",
"identity": "cpha3pharm"
}, {
"map": "who.focus",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"profile": "http://hl7.org/fhir/qicore/StructureDefinition/qicore-patient"
}, {
"code": "Reference",
"profile": "http://hl7.org/fhir/qicore/StructureDefinition/qicore-organization"
} ],
"mustSupport": true,
"max": "1",
"id": "Coverage:qicore-coverage.planholder[x]",
"base": {
"max": "1",
"min": 1,
"path": "Coverage.planholder[x]"
},
"isSummary": false
}, {
"path": "Coverage.beneficiaryReference",
"min": 1,
"definition": "The party who benefits from the insurance coverage.",
"short": "Plan Beneficiary",
"mapping": [ {
"map": "D01 through D09",
"identity": "cdanetv4"
}, {
"map": "IN1-16, 18, 19-name of insured, address, date of birth",
"identity": "v2"
}, {
"map": "C.35",
"identity": "cpha3pharm"
}, {
"map": "who.focus",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"profile": "http://hl7.org/fhir/qicore/StructureDefinition/qicore-patient"
} ],
"mustSupport": true,
"max": "1",
"id": "Coverage:qicore-coverage.beneficiaryReference",
"base": {
"max": "1",
"min": 1,
"path": "Coverage.beneficiary[x]"
},
"isSummary": false
}, {
"path": "Coverage.relationship",
"requirements": "To determine relationship between the patient and the subscriber.",
"min": 1,
"definition": "The relationship of beneficiary (patient) (subscriber) to the the planholder.",
"short": "Beneficiary relationship to Planholder",
"mapping": [ {
"map": "C03",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Coding"
} ],
"binding": {
"strength": "example",
"description": "The relationship between the Policyholder and the Beneficiary (insured/covered party/patient).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/policyholder-relationship"
}
},
"max": "1",
"id": "Coverage:qicore-coverage.relationship",
"base": {
"max": "1",
"min": 1,
"path": "Coverage.relationship"
}
}, {
"path": "Coverage.identifier",
"requirements": "This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below.",
"min": 0,
"definition": "The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Subscriber Id, Certificate number or Personal Health Number or Case ID.",
"short": "The primary coverage ID",
"mapping": [ {
"map": "C02",
"identity": "cdanetv4"
}, {
"map": "IN1-2",
"identity": "v2"
}, {
"map": "C.32, C.33, C.39",
"identity": "cpha3pharm"
}, {
"map": "id",
"identity": "w5"
} ],
"type": [ {
"code": "Identifier"
} ],
"max": "*",
"id": "Coverage:qicore-coverage.identifier",
"base": {
"max": "*",
"min": 0,
"path": "Coverage.identifier"
},
"isSummary": true
}, {
"path": "Coverage.group",
"min": 0,
"definition": "Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer group. May also be referred to as a Policy or Group ID.",
"short": "An identifier for the group",
"mapping": [ {
"map": "C11 (Division,Section)",
"identity": "cdanetv4"
}, {
"map": "IN1-8",
"identity": "v2"
}, {
"map": "C.31",
"identity": "cpha3pharm"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Coverage:qicore-coverage.group",
"base": {
"max": "1",
"min": 0,
"path": "Coverage.group"
},
"isSummary": true
}, {
"path": "Coverage.subGroup",
"min": 0,
"definition": "Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer group. May also be referred to as a Policy or Group ID.",
"short": "An identifier for the subsection of the group",
"mapping": [ {
"map": "IN1-8",
"identity": "v2"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Coverage:qicore-coverage.subGroup",
"base": {
"max": "1",
"min": 0,
"path": "Coverage.subGroup"
},
"isSummary": true
}, {
"path": "Coverage.plan",
"min": 0,
"definition": "Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer group. May also be referred to as a Policy or Group ID.",
"short": "An identifier for the plan",
"mapping": [ {
"map": "C01",
"identity": "cdanetv4"
}, {
"map": "IN1-35",
"identity": "v2"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Coverage:qicore-coverage.plan",
"base": {
"max": "1",
"min": 0,
"path": "Coverage.plan"
},
"isSummary": true
}, {
"path": "Coverage.subPlan",
"min": 0,
"definition": "Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a specific employer group within a class of employers. May be referred to as a Section or Division ID.",
"short": "An identifier for the subsection of the plan",
"mapping": [ {
"map": "IN1-10",
"identity": "v2"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Coverage:qicore-coverage.subPlan",
"base": {
"max": "1",
"min": 0,
"path": "Coverage.subPlan"
},
"isSummary": true
}, {
"path": "Coverage.class",
"min": 0,
"definition": "Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer group.",
"short": "An identifier for the class",
"mapping": [ {
"map": "C01",
"identity": "cdanetv4"
}, {
"map": "IN1-35",
"identity": "v2"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Coverage:qicore-coverage.class",
"base": {
"max": "1",
"min": 0,
"path": "Coverage.class"
},
"isSummary": true
}, {
"path": "Coverage.dependent",
"requirements": "For some coverage a single identifier is issued to the PolicyHolder and a dependent number issued to each beneficiary.",
"min": 0,
"definition": "A unique identifier for a dependent under the coverage.",
"short": "Dependent number",
"mapping": [ {
"map": "C17",
"identity": "cdanetv4"
}, {
"map": "- No exact HL7 v2 equivalent concept seems to exist;",
"identity": "v2"
} ],
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Coverage:qicore-coverage.dependent",
"base": {
"max": "1",
"min": 0,
"path": "Coverage.dependent"
},
"isSummary": true
}, {
"path": "Coverage.sequence",
"requirements": "Some coverage, for example social plans, may be offered in short time increments, for example for a week or a month at a time, so while the rest of the plan details and identifiers may remain constant over time, the instance is incremented with each renewal and provided to the covered party on their 'card'.",
"min": 0,
"definition": "An optional counter for a particular instance of the identified coverage which increments upon each renewal.",
"short": "The plan instance or sequence counter",
"mapping": [ {
"map": "D11",
"identity": "cdanetv4"
}, {
"map": "No HL7 v2 equivalent concept seems to exist",
"identity": "v2"
} ],
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Coverage:qicore-coverage.sequence",
"base": {
"max": "1",
"min": 0,
"path": "Coverage.sequence"
},
"isSummary": true
}, {
"path": "Coverage.network",
"min": 0,
"definition": "The identifier for a community of providers.",
"short": "Insurer network",
"mapping": [ {
"map": "D10",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Coverage:qicore-coverage.network",
"base": {
"max": "1",
"min": 0,
"path": "Coverage.network"
},
"isSummary": true
}, {
"path": "Coverage.contract",
"min": 0,
"definition": "The policy(s) which constitute this insurance coverage.",
"short": "Contract details",
"mapping": [ {
"map": "D01 through D09",
"identity": "cdanetv4"
}, {
"map": "IN1-16, 18, 19",
"identity": "v2"
}, {
"map": "C.35",
"identity": "cpha3pharm"
} ],
"type": [ {
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Contract"
} ],
"max": "*",
"id": "Coverage:qicore-coverage.contract",
"base": {
"max": "*",
"min": 0,
"path": "Coverage.contract"
}
} ]
},
"status": "draft",
"id": "acdc3d92-4b1c-4960-b9a9-347ebc1edb6f",
"kind": "resource",
"url": "http://hl7.org/fhir/qicore/StructureDefinition/qicore-coverage",
"version": null,
"differential": {
"element": [ {
"id": "Coverage:qicore-coverage",
"name": "QICore-Coverage",
"path": "Coverage",
"isSummary": false,
"isModifier": false,
"mustSupport": false
}, {
"id": "Coverage:qicore-coverage.issuerReference",
"path": "Coverage.issuerReference",
"type": [ {
"code": "Reference",
"profile": "http://hl7.org/fhir/qicore/StructureDefinition/qicore-patient"
}, {
"code": "Reference",
"profile": "http://hl7.org/fhir/qicore/StructureDefinition/qicore-organization"
}, {
"code": "Reference",
"profile": "http://hl7.org/fhir/qicore/StructureDefinition/qicore-relatedperson"
} ],
"isSummary": false,
"isModifier": false,
"mustSupport": true
}, {
"id": "Coverage:qicore-coverage.planholderReference",
"path": "Coverage.planholderReference",
"type": [ {
"code": "Reference",
"profile": "http://hl7.org/fhir/qicore/StructureDefinition/qicore-patient"
}, {
"code": "Reference",
"profile": "http://hl7.org/fhir/qicore/StructureDefinition/qicore-organization"
} ],
"isSummary": false,
"isModifier": false,
"mustSupport": true
}, {
"id": "Coverage:qicore-coverage.beneficiaryReference",
"path": "Coverage.beneficiaryReference",
"type": [ {
"code": "Reference",
"profile": "http://hl7.org/fhir/qicore/StructureDefinition/qicore-patient"
} ],
"isSummary": false,
"isModifier": false,
"mustSupport": true
} ]
},
"contact": [ {
"telecom": [ {
"value": "http://hl7.org/special/committees/CQI",
"system": "other"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/Coverage"
}