description: PCT Coverage is a profile for capturing data that reflect a payer's coverage that was effective as of the proposed date of service or the date of admission of the GFE.
package_name: hl7.fhir.us.davinci-pct.r4b
derivation: constraint
name: PCTCoverage
type: Coverage
elements:
  extension:
    index: 0
    slicing:
      rules: open
      ordered: false
      discriminator:
      - {path: url, type: value}
      min: 1
      slices:
        coverage-kind:
          match: {url: null}
          schema:
            type: Extension
            mustSupport: true
            url: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
            index: 1
            elements:
              value:
                choices: []
                index: 3
            required: [value]
        self-pay-declared:
          match: {url: null}
          schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared', index: 4}
          min: 0
          max: 1
  type: {short: Coverage category such as medical or accident. A coverage.type of `81` (Self-pay) MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs., index: 5}
  subscriber:
    short: Required if subscriber is a person that is not the beneficiary. When date of birth or gender are not known, omit Patient.birthDate and set Patient.gender to unknown.
    index: 6
    elements:
      display: {short: 'Provide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber''s prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference.', index: 7}
  subscriberId:
    index: 8
    extensions:
      dataAbsentReason:
        url: http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0
        type: Extension
        index: 10
        elements:
          value:
            short: Use Data Absent Reason (DAR) extension with a value of 'not-applicable' for self-pay or uninsured
            pattern: {type: Code, value: not-applicable}
            choices: []
            index: 12
    elements:
      extension:
        index: 9
        slicing:
          rules: open
          ordered: false
          discriminator:
          - {path: url, type: value}
          min: null
          slices:
            dataAbsentReason:
              match: {url: null}
              schema:
                type: Extension
                url: http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0
                index: 10
                elements:
                  value:
                    short: Use Data Absent Reason (DAR) extension with a value of 'not-applicable' for self-pay or uninsured
                    pattern: {type: Code, value: not-applicable}
                    choices: []
                    index: 12
  beneficiary: {short: Patient or Plan Beneficiary, index: 13}
  payor:
    type: Reference
    short: Issuer of the policy. For Self-pay or uninsured this should be a reference to a patient or related person resource
    refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson|7.0.0', 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization']
    index: 14
  class:
    index: 15
    elements:
      name: {index: 16}
    required: [name]
    slicing:
      slices:
        group:
          match: {}
          schema:
            index: 17
            elements:
              name: {index: 18}
            required: [name]
        plan:
          match: {}
          schema:
            index: 19
            elements:
              name: {index: 20}
            required: [name]
  costToBeneficiary:
    elements:
      type:
        binding: {strength: required, valueSet: 'http://terminology.hl7.org/ValueSet/coverage-copay-type|1.0.1'}
        index: 21
package_version: 2.0.0
extensions:
  coverage-kind:
    url: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    type: Extension
    mustSupport: true
    index: 1
    elements:
      value:
        choices: []
        index: 3
    required: [value]
  self-pay-declared: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared', min: 0, max: 1, type: Extension, mustSupport: true, index: 4}
class: profile
kind: resource
url: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage
base: http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage|7.0.0
version: 2.0.0
required: [subscriberId, extension]