醫療保險理賠實作指引
0.1.3 - CI Build

This page is part of the 醫療保險理賠實作指引 (v0.1.3: Releases Ballot 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Resource Profile: CoverageiClaim - Detailed Descriptions

Active as of 2023-12-25

Definitions for the coverage-iclaim resource profile.

Guidance on how to interpret the contents of this table can be found here

0. Coverage
2. Coverage.beneficiary
TypeReference(Patient iClaim)
4. Coverage.payor
Control0..1
TypeReference(TW Core Organization Company)

Guidance on how to interpret the contents of this table can be found here

0. Coverage
Definition

Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.

ShortInsurance or medical plan or a payment agreement
Comments

The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.

Control0..*
Is Modifierfalse
Summaryfalse
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. Coverage.implicitRules
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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA 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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because 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
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. Coverage.modifierExtension
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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions 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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
6. Coverage.status
Definition

The status of the resource instance.

Shortactive | cancelled | draft | entered-in-error
Comments

This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1

A code specifying the state of the resource instance.

Typecode
Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. Coverage.beneficiary
Definition

The party who benefits from the insurance coverage; the patient when products and/or services are provided.

ShortPlan beneficiary
Control1..1
TypeReference(Patient iClaim, Patient)
Is Modifierfalse
Summarytrue
Requirements

This is the party who receives treatment for which the costs are reimbursed under the coverage.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. Coverage.payor
Definition

The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.

ShortIssuer of the policy
Comments

May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations.

Control1..1*
TypeReference(TW Core Organization Company, Organization, Patient, RelatedPerson)
Is Modifierfalse
Summarytrue
Requirements

Need to identify the issuer to target for claim processing and for coordination of benefit processing.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be found here

0. Coverage
Definition

Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.

ShortInsurance or medical plan or a payment agreement
Comments

The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.

Control0..*
Is Modifierfalse
Summaryfalse
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. Coverage.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

ShortLogical 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.

Control0..1
Typeid
Is Modifierfalse
Summarytrue
4. Coverage.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

ShortMetadata about the resource
Control0..1
TypeMeta
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. Coverage.implicitRules
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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA 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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because 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
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. Coverage.language
Definition

The base language in which the resource is written.

ShortLanguage 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).

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages

A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. Coverage.text
Definition

A human-readable narrative that contains a summary of the resource and can 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.

ShortText 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 information is added later.

Control0..1
TypeNarrative
Is Modifierfalse
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. Coverage.contained
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.

ShortContained, 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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Control0..*
TypeResource
Is Modifierfalse
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
14. Coverage.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional 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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
16. Coverage.modifierExtension
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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions 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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
18. Coverage.identifier
Definition

A unique identifier assigned to this coverage.

ShortBusiness Identifier for the coverage
Comments

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 concatenation of the Coverage.SubscriberID and the Coverage.dependant.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Is Modifierfalse
Summarytrue
Requirements

Allows coverages to be distinguished and referenced.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. Coverage.status
Definition

The status of the resource instance.

Shortactive | cancelled | draft | entered-in-error
Comments

This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodes

A code specifying the state of the resource instance.

Typecode
Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. Coverage.type
Definition

The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.

ShortCoverage category such as medical or accident
Control0..1
BindingThe codes SHOULD be taken from CoverageTypeAndSelf-PayCodes

The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.

TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

The order of application of coverages is dependent on the types of coverage.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. Coverage.policyHolder
Definition

The party who 'owns' the insurance policy.

ShortOwner of the policy
Comments

For example: may be an individual, corporation or the subscriber's employer.

Control0..1
TypeReference(Patient, RelatedPerson, Organization)
Is Modifierfalse
Summarytrue
Requirements

This provides employer information in the case of Worker's Compensation and other policies.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. Coverage.subscriber
Definition

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.

ShortSubscriber to the policy
Comments

May be self or a parent in the case of dependants.

Control0..1
TypeReference(Patient, RelatedPerson)
Is Modifierfalse
Summarytrue
Requirements

This is the party who is entitled to the benfits under the policy.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. Coverage.subscriberId
Definition

The insurer assigned ID for the Subscriber.

ShortID assigned to the subscriber
Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

The insurer requires this identifier on correspondance and claims (digital and otherwise).

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. Coverage.beneficiary
Definition

The party who benefits from the insurance coverage; the patient when products and/or services are provided.

ShortPlan beneficiary
Control1..1
TypeReference(Patient iClaim)
Is Modifierfalse
Summarytrue
Requirements

This is the party who receives treatment for which the costs are reimbursed under the coverage.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. Coverage.dependent
Definition

A unique identifier for a dependent under the coverage.

ShortDependent number
Comments

Periodically the member number is constructed from the subscriberId and the dependant number.

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

For some coverages a single identifier is issued to the Subscriber and then a unique dependent number is issued to each beneficiary.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. Coverage.relationship
Definition

The relationship of beneficiary (patient) to the subscriber.

ShortBeneficiary relationship to the subscriber
Comments

Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.

Control0..1
BindingUnless not suitable, these codes SHALL be taken from SubscriberRelationshipCodes

The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

To determine relationship between the patient and the subscriber to determine coordination of benefits.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. Coverage.period
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.

ShortCoverage start and end dates
Control0..1
TypePeriod
Is Modifierfalse
Summarytrue
Requirements

Some insurers require the submission of the coverage term.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. Coverage.payor
Definition

The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.

ShortIssuer of the policy
Comments

May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations.

Control1..1
TypeReference(TW Core Organization Company)
Is Modifierfalse
Summarytrue
Requirements

Need to identify the issuer to target for claim processing and for coordination of benefit processing.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. Coverage.class
Definition

A suite of underwriter specific classifiers.

ShortAdditional coverage classifications
Comments

For example may be used to identify a class of coverage or employer group, Policy, Plan.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

The codes provided on the health card which identify or confirm the specific policy for the insurer.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. Coverage.class.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
44. Coverage.class.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional 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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
46. Coverage.class.modifierExtension
Definition

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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
48. Coverage.class.type
Definition

The type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan.

ShortType of class such as 'group' or 'plan'
Control1..1
BindingUnless not suitable, these codes SHALL be taken from CoverageClassCodes

The policy classifications, eg. Group, Plan, Class, etc.

TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

The insurer issued label for a specific health card value.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. Coverage.class.value
Definition

The alphanumeric string value associated with the insurer issued label.

ShortValue associated with the type
Comments

For example, the Group or Plan number.

Control1..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

The insurer issued label and value are necessary to identify the specific policy.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. Coverage.class.name
Definition

A short description for the class.

ShortHuman readable description of the type and value
Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Used to provide a meaningful description in correspondence to the patient.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. Coverage.order
Definition

The order of applicability of this coverage relative to other coverages which are currently in force. Note, there may be gaps in the numbering and this does not imply primary, secondary etc. as the specific positioning of coverages depends upon the episode of care.

ShortRelative order of the coverage
Control0..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Used in managing the coordination of benefits.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. Coverage.network
Definition

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.

ShortInsurer network
Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Used in referral for treatment and in claims processing.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. Coverage.costToBeneficiary
Definition

A suite of codes indicating the cost category and associated amount which have been detailed in the policy and may have been included on the health card.

ShortPatient payments for services/products
Comments

For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

Required by providers to manage financial transaction with the patient.

Alternate NamesCoPay, Deductible, Exceptions
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
60. Coverage.costToBeneficiary.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
62. Coverage.costToBeneficiary.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional 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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
64. Coverage.costToBeneficiary.modifierExtension
Definition

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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
66. Coverage.costToBeneficiary.type
Definition

The category of patient centric costs associated with treatment.

ShortCost category
Comments

For example visit, specialist visits, emergency, inpatient care, etc.

Control0..1
BindingUnless not suitable, these codes SHALL be taken from CoverageCopayTypeCodes

The types of services to which patient copayments are specified.

TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

Needed to identify the category associated with the amount for the patient.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
68. Coverage.costToBeneficiary.value[x]
Definition

The amount due from the patient for the cost category.

ShortThe amount or percentage due from the beneficiary
Comments

Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.

Control1..1
TypeChoice of: Quantity(SimpleQuantity), Money
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifierfalse
Summarytrue
Requirements

Needed to identify the amount for the patient associated with the category.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
70. Coverage.costToBeneficiary.exception
Definition

A suite of codes indicating exceptions or reductions to patient costs and their effective periods.

ShortExceptions for patient payments
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

Required by providers to manage financial transaction with the patient.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
72. Coverage.costToBeneficiary.exception.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
74. Coverage.costToBeneficiary.exception.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional 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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
76. Coverage.costToBeneficiary.exception.modifierExtension
Definition

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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
78. Coverage.costToBeneficiary.exception.type
Definition

The code for the specific exception.

ShortException category
Control1..1
BindingFor example codes, see ExampleCoverageFinancialExceptionCodes

The types of exceptions from the part or full value of financial obligations such as copays.

TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

Needed to identify the exception associated with the amount for the patient.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
80. Coverage.costToBeneficiary.exception.period
Definition

The timeframe during when the exception is in force.

ShortThe effective period of the exception
Control0..1
TypePeriod
Is Modifierfalse
Summarytrue
Requirements

Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
82. Coverage.subrogation
Definition

When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs.

ShortReimbursement to insurer
Comments

Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.

Control0..1
Typeboolean
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

See definition for when to be used.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
84. Coverage.contract
Definition

The policy(s) which constitute this insurance coverage.

ShortContract details
Control0..*
TypeReference(Contract)
Is Modifierfalse
Summaryfalse
Requirements

To reference the legally binding contract between the policy holder and the insurer.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))