Generated Narrative: StructureDefinition ke-eclaims-coverage Name Flags Card. Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> Coverage 0..* Coverage Insurance or medical plan or a payment agreement #xD; id S 1..1 id Logical id of this artifact #xD; meta S 1..1 Meta Metadata about the resource #xD; profile S 1..* canonical(StructureDefinition) Profiles this resource claims to conform to #xD; Slices for extension 1..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:paymentMethod S 0..1 (Complex) Paymen tMethod Extension URL: https://fhir.dha.go.ke/eclaims/StructureDefinition/payment-method-extension #xD; value[x] 1..1 CodeableConcept Value of extension Binding: Payment Method ValueSet (required) #xD; extension:memberStatus S 0..1 (Complex) Current member status Extension URL: https://fhir.dha.go.ke/eclaims/StructureDefinition/member-status-extension #xD; value[x] 1..1 CodeableConcept Value of extension Binding: Coverage Member Status ValueSet (required) #xD; extension:planType S 0..1 (Complex) Plan Type Extension URL: https://fhir.dha.go.ke/eclaims/StructureDefinition/plan-type-extension #xD; value[x] 1..1 CodeableConcept Value of extension Binding: Coverage Plan Type ValueSet (required) #xD; extension:annualLimitsCategory S 1..1 (Complex) Annual Limits Category Extension URL: https://fhir.dha.go.ke/eclaims/StructureDefinition/annual-limit-category-extension #xD; value[x] 1..1 CodeableConcept Value of extension Binding: ServiceCategory (required) #xD; extension:exclusion S 0..* CodeableConcept Exclusion Extension URL: https://fhir.dha.go.ke/eclaims/StructureDefinition/exclusion-extension Binding: Coverage Exclusion Reason ValueSet (required) #xD; extension:preAuthExclusions S 0..* CodeableConcept Preauthorization Expiry Date URL: https://fhir.dha.go.ke/eclaims/StructureDefinition/pre-auth-exclusion-extension Binding: Preauthorization Exclusion Reason ValueSet (required) #xD; extension:waiverType S 0..1 CodeableConcept Preauthorization Expiry Date URL: https://fhir.dha.go.ke/eclaims/StructureDefinition/waiver-type-extension Binding: Waiver Type ValueSet (required) #xD; identifier S 1..* Identifier Business Identifier for the coverage #xD; system S 1..1 uri The namespace for the identifier value #xD; value S 1..1 string The value that is unique #xD; status S 1..1 code active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required) #xD; type S 0..1 CodeableConcept Coverage category such as medical or accident Binding: Coverage Type ValueSet (required) #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; subscriber S 1..1 Reference(eClaims Patient Profile) Subscriber to the policy #xD; beneficiary S 1..1 Reference(eClaims Patient Profile) Plan beneficiary #xD; reference 1..1 string Literal reference, Relative, internal or absolute URL #xD; type 1..1 uri Type the reference refers to (e.g. "Patient") #xD; relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (required) #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; period S 0..1 Period Coverage start and end dates #xD; payor S 1..1 Reference(eClaims Organization Profile) Issuer of the policy #xD; class S 1..* BackboneElement Additional coverage classifications #xD; type S 1..1 CodeableConcept Type of class such as 'group' or 'plan' Binding: Coverage Class ValueSet (required) #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; value S 1..1 string Value associated with the type #xD; costToBeneficiary S 0..* BackboneElement Patient payments for services/products #xD; type S 0..1 CodeableConcept Cost category Binding: CoverageCopayTypeCodes (required) #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; exception S 0..* BackboneElement Exceptions for patient payments #xD; type S 1..1 CodeableConcept Exception category Binding: ExampleCoverageFinancialExceptionCodes (required) #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; <img src="[binary]" alt="doco" style="background-color: inherit"/> Documentation for this format
This profile defines constraints on the Coverage resource for use within the Kenya eClaims Implementation Guide. It represents insurance coverage for a patient under a specific insurance scheme, including SHA and specialised schemes such as POMF and POMF_TEACHERS.
Canadian Dental Association eclaims standard
Canadian Pharmacy Associaiton eclaims standard
Insurance or medical plan or a payment agreement
Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.
The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
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()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
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()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
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 might not always be associated with version changes to the resource.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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 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.
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.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
When the resource last changed - e.g. when the version changed.
This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a [read](http://hl7.org/fhir/R4/http.html#read) interaction.
Identifies where the resource comes from
A uri that identifies the source system of the resource. This provides a minimal amount of [Provenance](http://hl7.org/fhir/R4/provenance.html#) information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.
In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
Profiles this resource claims to conform to
A list of profiles (references to [StructureDefinition](http://hl7.org/fhir/R4/structuredefinition.html#) resources) that this resource claims to conform to. The URL is a reference to [StructureDefinition.url](http://hl7.org/fhir/R4/structuredefinition-definitions.html#StructureDefinition.url).
It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
Security Labels applied to this resource
Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Security Labels from the Healthcare Privacy and Security Classification System.
Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
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.
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 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.
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.
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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
The preferred method of payment for the beneficiary's share (e.g., credit card, direct debit).
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
Source of the definition for the extension code - a logical name or a URL.
The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
Value of extension - must be one of a constrained set of the data types (see [Extensibility](http://hl7.org/fhir/R4/extensibility.html) for a list).
The category of service to which the limit applies.
A list of services or conditions that are explicitly not covered by this plan.
Services excluded from preauthorization.
Indicates when the approved preauthorization expires.
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).
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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
A unique identifier assigned to this coverage.
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.
Allows coverages to be distinguished and referenced.
usual | official | temp | secondary | old (If known)
Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Identifies the purpose for this identifier, if known .
A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.
Allows users to make use of identifiers when the identifier system is not known.
A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
Identifier.system is always case sensitive.
There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the [Rendered Value extension](http://hl7.org/fhir/R4/extension-rendered-value.html). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)
Time period when id is/was valid for use
Time period during which identifier is/was valid for use.
Role.effectiveTime or implied by context
Organization that issued id (may be just text)
Organization that issued/manages the identifier.
The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper
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.
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'.
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
Coverage category 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.
The order of application of coverages is dependent on the types of coverage.
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 alternative encodings within a code system, and translations to other code systems.
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 reference to some definition that establishes 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 - e.g. 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.
For example: may be an individual, corporation or the subscriber's employer.
This provides employer information in the case of Worker's Compensation and other policies.
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.
May be self or a parent in the case of dependants.
This is the party who is entitled to the benfits under the policy.
The insurer assigned ID for the Subscriber.
The insurer requires this identifier on correspondance and claims (digital and otherwise).
The party who benefits from the insurance coverage; the patient when products and/or services are provided.
This is the party who receives treatment for which the costs are reimbursed under the coverage.
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.
Type the reference refers to (e.g. "Patient")
The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Aa resource (or, for logical models, the URI of the logical model).
Logical reference, when literal reference is not known
An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents 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. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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.
A unique identifier for a dependent under the coverage.
Periodically the member number is constructed from the subscriberId and the dependant number.
For some coverages a single identifier is issued to the Subscriber and then a unique dependent number is issued to each beneficiary.
- No exact HL7 v2 equivalent concept seems to exist;
Beneficiary relationship to the subscriber
The relationship of beneficiary (patient) to the subscriber.
Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.
To determine relationship between the patient and the subscriber to determine coordination of benefits.
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.
Some insurers require the submission of the coverage term.
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). For selfpay it may provide multiple paying persons and/or organizations.
Need to identify the issuer to target for claim processing and for coordination of benefit processing.
A suite of underwriter specific classifiers.
For example may be used to identify a class of coverage or employer group, Policy, Plan.
The codes provided on the health card which identify or confirm the specific policy for the insurer.
Extensions that cannot be ignored even if unrecognized
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).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
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.
The insurer issued label for a specific health card value.
The alphanumeric string value associated with the insurer issued label.
The insurer issued label and value are necessary to identify the specific policy.
Human readable description of the type and value
Used to provide a meaningful description in correspondence to the patient.
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.
Used in managing the coordination of benefits.
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.
Used in referral for treatment and in claims processing.
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.
For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.
Required by providers to manage financial transaction with the patient.
The category of patient centric costs associated with treatment.
For example visit, specialist visits, emergency, inpatient care, etc.
Needed to identify the category associated with the amount for the patient.
The amount or percentage due from the beneficiary
The amount due from the patient for the cost category.
Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.
Needed to identify the amount for the patient associated with the category.
A suite of codes indicating exceptions or reductions to patient costs and their effective periods.
Needed to identify the exception associated with the amount for the patient.
The timeframe during when the exception is in force.
Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs.
When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs.
Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.
The policy(s) which constitute this insurance coverage.
To reference the legally binding contract between the policy holder and the insurer.