FHIR Implementation Guide for ABDM
5.0.0 - active
India
FHIR Implementation Guide for ABDM - Local Development build (v5.0.0). See the Directory of published versions
Official URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Coverage | Version: 5.0.0 | |||
Draft as of 2023-12-22 | Computable Name: Coverage |
This profile aims to capture essential identifiers and descriptors of an insurance plan through the Coverage resource. It encompasses information that is typically found on an insurance card and can be utilized to cover the costs, either partially or entirely, for healthcare products and services.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Coverage
Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
![]() ![]() | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
![]() ![]() ![]() | 0..1 | Reference(RelatedPerson | Organization | Patient) | Owner of the policy | |
![]() ![]() ![]() | 0..1 | Reference(RelatedPerson | Patient) | Subscriber to the policy | |
![]() ![]() ![]() | 1..1 | Reference(Patient) | Plan beneficiary | |
![]() ![]() ![]() | 1..* | Reference(RelatedPerson | Patient | Organization) | Issuer of the policy | |
![]() |
Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
![]() ![]() | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
![]() ![]() ![]() | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
![]() ![]() ![]() | ?! | 0..* | Extension | Extensions that cannot be ignored |
![]() ![]() ![]() | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
![]() ![]() ![]() | Σ | 0..1 | Reference(RelatedPerson | Organization | Patient) | Owner of the policy |
![]() ![]() ![]() | Σ | 0..1 | Reference(RelatedPerson | Patient) | Subscriber to the policy |
![]() ![]() ![]() | Σ | 1..1 | Reference(Patient) | Plan beneficiary |
![]() ![]() ![]() | Σ | 1..* | Reference(RelatedPerson | Patient | Organization) | Issuer of the policy |
![]() |
Path | Conformance | ValueSet |
Coverage.status | required | FinancialResourceStatusCodes |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Coverage | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints![]() | ||||
---|---|---|---|---|---|---|---|---|
![]() ![]() | 0..* | Coverage | Insurance or medical plan or a payment agreement | |||||
![]() ![]() ![]() | Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() ![]() | Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() ![]() | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() ![]() | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() ![]() | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
![]() ![]() ![]() | 0..* | Resource | Contained, inline Resources | |||||
![]() ![]() ![]() | 0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() ![]() | Σ | 0..* | Identifier | Business Identifier for the coverage | ||||
![]() ![]() ![]() | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
![]() ![]() ![]() | Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. | ||||
![]() ![]() ![]() | Σ | 0..1 | Reference(RelatedPerson | Organization | Patient) | Owner of the policy | ||||
![]() ![]() ![]() | Σ | 0..1 | Reference(RelatedPerson | Patient) | Subscriber to the policy | ||||
![]() ![]() ![]() | Σ | 0..1 | string | ID assigned to the subscriber | ||||
![]() ![]() ![]() | Σ | 1..1 | Reference(Patient) | Plan beneficiary | ||||
![]() ![]() ![]() | Σ | 0..1 | string | Dependent number | ||||
![]() ![]() ![]() | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). | |||||
![]() ![]() ![]() | Σ | 0..1 | Period | Coverage start and end dates | ||||
![]() ![]() ![]() | Σ | 1..* | Reference(RelatedPerson | Patient | Organization) | Issuer of the policy | ||||
![]() ![]() ![]() | 0..* | BackboneElement | Additional coverage classifications | |||||
![]() ![]() ![]() ![]() | 0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() | 0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. | ||||
![]() ![]() ![]() ![]() | Σ | 1..1 | string | Value associated with the type | ||||
![]() ![]() ![]() ![]() | Σ | 0..1 | string | Human readable description of the type and value | ||||
![]() ![]() ![]() | Σ | 0..1 | positiveInt | Relative order of the coverage | ||||
![]() ![]() ![]() | Σ | 0..1 | string | Insurer network | ||||
![]() ![]() ![]() | 0..* | BackboneElement | Patient payments for services/products | |||||
![]() ![]() ![]() ![]() | 0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() | 0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified. | ||||
![]() ![]() ![]() ![]() | Σ | 1..1 | The amount or percentage due from the beneficiary | |||||
![]() ![]() ![]() ![]() ![]() | Quantity(SimpleQuantity) | |||||||
![]() ![]() ![]() ![]() ![]() | Money | |||||||
![]() ![]() ![]() ![]() | 0..* | BackboneElement | Exceptions for patient payments | |||||
![]() ![]() ![]() ![]() ![]() | 0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() | 0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() | Σ | 1..1 | CodeableConcept | Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays. | ||||
![]() ![]() ![]() ![]() ![]() | Σ | 0..1 | Period | The effective period of the exception | ||||
![]() ![]() ![]() | 0..1 | boolean | Reimbursement to insurer | |||||
![]() ![]() ![]() | 0..* | Reference(Contract) | Contract details | |||||
![]() |
Path | Conformance | ValueSet | ||||
Coverage.language | preferred | CommonLanguages
| ||||
Coverage.status | required | FinancialResourceStatusCodes | ||||
Coverage.type | preferred | CoverageTypeAndSelf-PayCodes | ||||
Coverage.relationship | extensible | SubscriberRelationshipCodes | ||||
Coverage.class.type | extensible | CoverageClassCodes | ||||
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes | ||||
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Coverage | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Coverage
Differential View
This structure is derived from Coverage
Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
![]() ![]() | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
![]() ![]() ![]() | 0..1 | Reference(RelatedPerson | Organization | Patient) | Owner of the policy | |
![]() ![]() ![]() | 0..1 | Reference(RelatedPerson | Patient) | Subscriber to the policy | |
![]() ![]() ![]() | 1..1 | Reference(Patient) | Plan beneficiary | |
![]() ![]() ![]() | 1..* | Reference(RelatedPerson | Patient | Organization) | Issuer of the policy | |
![]() |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
![]() ![]() | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
![]() ![]() ![]() | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
![]() ![]() ![]() | ?! | 0..* | Extension | Extensions that cannot be ignored |
![]() ![]() ![]() | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
![]() ![]() ![]() | Σ | 0..1 | Reference(RelatedPerson | Organization | Patient) | Owner of the policy |
![]() ![]() ![]() | Σ | 0..1 | Reference(RelatedPerson | Patient) | Subscriber to the policy |
![]() ![]() ![]() | Σ | 1..1 | Reference(Patient) | Plan beneficiary |
![]() ![]() ![]() | Σ | 1..* | Reference(RelatedPerson | Patient | Organization) | Issuer of the policy |
![]() |
Path | Conformance | ValueSet |
Coverage.status | required | FinancialResourceStatusCodes |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Coverage | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints![]() | ||||
---|---|---|---|---|---|---|---|---|
![]() ![]() | 0..* | Coverage | Insurance or medical plan or a payment agreement | |||||
![]() ![]() ![]() | Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() ![]() | Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() ![]() | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() ![]() | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() ![]() | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
![]() ![]() ![]() | 0..* | Resource | Contained, inline Resources | |||||
![]() ![]() ![]() | 0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() ![]() | Σ | 0..* | Identifier | Business Identifier for the coverage | ||||
![]() ![]() ![]() | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
![]() ![]() ![]() | Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. | ||||
![]() ![]() ![]() | Σ | 0..1 | Reference(RelatedPerson | Organization | Patient) | Owner of the policy | ||||
![]() ![]() ![]() | Σ | 0..1 | Reference(RelatedPerson | Patient) | Subscriber to the policy | ||||
![]() ![]() ![]() | Σ | 0..1 | string | ID assigned to the subscriber | ||||
![]() ![]() ![]() | Σ | 1..1 | Reference(Patient) | Plan beneficiary | ||||
![]() ![]() ![]() | Σ | 0..1 | string | Dependent number | ||||
![]() ![]() ![]() | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). | |||||
![]() ![]() ![]() | Σ | 0..1 | Period | Coverage start and end dates | ||||
![]() ![]() ![]() | Σ | 1..* | Reference(RelatedPerson | Patient | Organization) | Issuer of the policy | ||||
![]() ![]() ![]() | 0..* | BackboneElement | Additional coverage classifications | |||||
![]() ![]() ![]() ![]() | 0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() | 0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. | ||||
![]() ![]() ![]() ![]() | Σ | 1..1 | string | Value associated with the type | ||||
![]() ![]() ![]() ![]() | Σ | 0..1 | string | Human readable description of the type and value | ||||
![]() ![]() ![]() | Σ | 0..1 | positiveInt | Relative order of the coverage | ||||
![]() ![]() ![]() | Σ | 0..1 | string | Insurer network | ||||
![]() ![]() ![]() | 0..* | BackboneElement | Patient payments for services/products | |||||
![]() ![]() ![]() ![]() | 0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() | 0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified. | ||||
![]() ![]() ![]() ![]() | Σ | 1..1 | The amount or percentage due from the beneficiary | |||||
![]() ![]() ![]() ![]() ![]() | Quantity(SimpleQuantity) | |||||||
![]() ![]() ![]() ![]() ![]() | Money | |||||||
![]() ![]() ![]() ![]() | 0..* | BackboneElement | Exceptions for patient payments | |||||
![]() ![]() ![]() ![]() ![]() | 0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() | 0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() | Σ | 1..1 | CodeableConcept | Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays. | ||||
![]() ![]() ![]() ![]() ![]() | Σ | 0..1 | Period | The effective period of the exception | ||||
![]() ![]() ![]() | 0..1 | boolean | Reimbursement to insurer | |||||
![]() ![]() ![]() | 0..* | Reference(Contract) | Contract details | |||||
![]() |
Path | Conformance | ValueSet | ||||
Coverage.language | preferred | CommonLanguages
| ||||
Coverage.status | required | FinancialResourceStatusCodes | ||||
Coverage.type | preferred | CoverageTypeAndSelf-PayCodes | ||||
Coverage.relationship | extensible | SubscriberRelationshipCodes | ||||
Coverage.class.type | extensible | CoverageClassCodes | ||||
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes | ||||
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Coverage | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Coverage
Other representations of profile: CSV, Excel, Schematron