Name Flags Card. Type Description & Constraints Coverage 0..* Coverage resource id 1.. meta ..0 implicitRules ..0 language ..0 text ..0 contained ..0 identifier ..0 status 1.. type 1.. coding 1..1 system 1.. version ..0 code 1.. display ..0 userSelected ..0 text ..0 policyHolder ..0 subscriber ..0 subscriberId ..0 beneficiary 1.. reference 1.. identifier ..0 display ..0 relationship ..0 period ..0 payor ..0 grouping 1.. id ..0 group ..0 groupDisplay ..0 subGroup 1.. subGroupDisplay ..0 plan ..0 planDisplay ..0 subPlan 1.. subPlanDisplay ..0 class ..0 classDisplay ..0 subClass ..0 subClassDisplay ..0 dependent ..0 sequence ..0 order ..0 network ..0 contract ..0 bluebutton-coverage-a-trm-cd-extension ..1 Coding Optional Extensions Element URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-a-trm-cd-extension Binding: Part A Termination Code (required) bluebutton-coverage-b-trm-cd-extension ..1 Coding Optional Extensions Element URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-b-trm-cd-extension Binding: Part B Termination Code (required) bluebutton-coverage-crec-extension ..1 Coding Optional Extensions Element URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-crec-extension Binding: Current Reason for Entitlement Code (required) bluebutton-coverage-esrd-ind-extension ..1 Coding Optional Extensions Element URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-esrd-ind-extension Binding: End-stage Renal Disease (ESRD) Indicator (required) bluebutton-coverage-ms-cd-extension ..1 Coding Optional Extensions Element URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-ms-cd-extension Binding: https://bluebutton.cms.gov/assets/ig/ValueSet-ms-cd (required) bluebutton-coverage-orec-extension ..1 Coding Optional Extensions Element URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-orec-extension Binding: Original Reason for Entitlement Code (required) Documentation for this format
Coverage profile for the Blue Button project.
Insurance or medical plan or a payment agreement
Financial instrument which may be used to reimburse or pay for health care products and services.
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
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.
A set of rules under which this content was created
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.
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. This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.
The base language in which the resource is written.
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).
Text summary of the resource, for human interpretation
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.
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.
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.
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.
Extensions are always sliced by (at least) url
Additional Content defined by implementations
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.
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.
Optional Extension Element - found in all resources.
End-stage Renal Disease (ESRD) Indicator
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.
The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatination of the Coverage.SubscriberID and the Coverage.dependent.
This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below.
CX / EI (occasionally, more often EI maps to a resource id or a URL)
II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
active | cancelled | draft | entered-in-error
This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.
A code specifying the state of the resource instance.
Type of coverage such as medical or accident
The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.
Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
The order of application of coverages is dependent on the types of coverage.
The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.
fhir:CodeableConcept rdfs:subClassOf dt:CD
unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Note that FHIR strings may not exceed 1MB in size
May be used to represent additional information that is not part of the basic definition of the element. 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.
A reference to a code defined by a terminology system.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.
CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
The identification of the code system that defines the meaning of the symbol in the code.
The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
Need to be unambiguous about the source of the definition of the symbol.
fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Need to refer to a particular code in the system.
fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
A representation of the meaning of the code in the system, following the rules of the system.
Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
C*E.2 - but note this is not well followed
fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
If this coding was chosen directly by the user
Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).
Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Plain text representation of the concept
A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Very often the text is the same as a displayName of one of the codings.
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
C*E.9. But note many systems use C*E.2 for this
fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])
The target of a resource reference is a RIM entry point (Act, Role, or Entity)
IN1-16, 18, 19-name of insured, address, date of birth
The party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due.
The insurer assigned ID for the Subscriber.
The party who benefits from the insurance coverage., the patient when services are provided.
Literal reference, Relative, internal or absolute URL
A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
Logical reference, when literal reference is not known
An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.
Plain text narrative that identifies the resource in addition to the resource reference.
This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
Beneficiary relationship to the Subscriber
The relationship of beneficiary (patient) to the subscriber.
To determine relationship between the patient and the subscriber.
The relationship between the Policyholder and the Beneficiary (insured/covered party/patient).
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.
This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). If duration is required, specify the type as Interval|Duration.
If present, start SHALL have a lower value than end
start.empty() or end.empty() or (start <= end)
not(exists(f:start)) or not(exists(f:end)) or (f:start/@value <= f:end/@value)
IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"]
Identifier for the plan or agreement issuer
The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements. May provide multiple identifiers such as insurance company identifier or business identifier (BIN number).
Need to identify the issuer to target for processing and for coordination of benefit processing.
A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan.
May be used to represent additional information that is not part of the basic definition of the element, 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.
Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify an employer group. May also be referred to as a Policy or Group ID.
Display text for an identifier for the group
An identifier for the subsection of the group
Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a subset of an employer group.
Display text for the subsection of the group
Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a collection of benefits provided to employees. May be referred to as a Section or Division ID.
An identifier for the subsection of the plan
Identifies a sub-style or sub-collective of coverage issued by the underwriter, for example may be used to identify a subset of a collection of benefits provided to employees.
Display text for the subsection of the plan
Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage such as a level of deductibles or co-payment.
An identifier for the subsection of the class
Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a subclass of coverage such as a sub-level of deductibles or co-payment.
Display text for the subsection of the subclass
A unique identifier for a dependent under the coverage.
For some coverage a single identifier is issued to the Subscriber and a dependent number issued to each beneficiary.
- No exact HL7 v2 equivalent concept seems to exist;
An optional counter for a particular instance of the identified coverage which increments upon each renewal.
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'.
No HL7 v2 equivalent concept seems to exist
The order of applicability of this coverage relative to other coverages which are currently inforce. Note, there may be gaps in the numbering and this does not imply primary, secondard etc. as the specific positioning of coverages depends upon the episode of care.
32 bit number; for values larger than this, use decimal
The insurer-specific identifier for the insurer-defined network of providers to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply.
The policy(s) which constitute this insurance coverage.
This resource provides the profile for the Coverage information.