Specialty Medication Enrollment
0.1.0 - STU1 Ballot

Publication Build: This will be filled in by the publication tooling

## Resource Profile: Specialty Rx Coverage

Defining URL: | http://hl7.org/fhir/us/specialty-rx/StructureDefinition/specialty-rx-coverage
Version: | 0.1.0
Name: | SpecialtyRxCoverage
Title: | Specialty Rx Coverage
Status: | Active as of 2020-12-11T00:00:00-05:00
Definition: | This profile constrains the Coverage resource for carrying insurance coverage information in the specialty medication enrollment process
Publisher: | HL7 International - Pharmacy
Source Resource: | XML / JSON / Turtle

The official URL for this profile is:

    http://hl7.org/fhir/us/specialty-rx/StructureDefinition/specialty-rx-coverage

The Coverage elements available to be used by the Specialty Rx process are:

- Coverage.subscriberId: Health plan subscriber ID
- Coverage.subscriber: Subscriber demographic information
- Coverage.identifier: Health plan member ID
- Coverage.beneficiary: Patient demographic information
- Coverage.class=rxid. Pharmacy benefit Member ID
- Coverage.class=rxgroup. Pharmacy benefit Group ID
- Coverage.class=rxbin. Pharmacy benefit BIN (IIN)
- Coverage.class=rxpcn. Pharmacy benefit PCN

The elements identified as Must Support are the typical set used in US pharmacy benefit processing.

### Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

- Text Summary
- Differential Table
- Snapshot Table
- Snapshot Table (Must Support)
- All

This structure is derived from Coverage

Summary

Mandatory: 0 element (4 nested mandatory elements)
Must-Support: 8 elements

Slices

This structure defines the following Slices:

- The element Coverage.class is sliced based on the value of value:type

This structure is derived from Coverage

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
identifier | S | 0..* | Identifier | Member identifier
subscriberId | S | 0..1 | string | Health Plan Subscriber ID
payor | S | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy
class | S | 0..* | (Slice Definition) | Pharmacy coverage identifiers Slice: Unordered, Open by value:type
class:All Slices |  |  |  | Content/Rules for all slices
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes
class:bin | S | 0..1 | BackboneElement | IIN (BIN) number
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin
class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN)
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn
class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup
class:pbm-member-id | S | 0..1 | BackboneElement | PBM Member ID
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
id | Σ | 0..1 | string | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language.
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 0..* | Identifier | Member identifier
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | 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.
policyHolder | Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy
subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy
subscriberId | S Σ | 0..1 | string | Health Plan Subscriber ID
beneficiary | Σ | 1..1 | Reference(Patient) | Plan beneficiary
dependent | Σ | 0..1 | string | Dependent number
relationship |  | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
period | Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy
class | S | 0..* | (Slice Definition) | Pharmacy coverage identifiers Slice: Unordered, Open by value:type
class:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:bin | S | 0..1 | BackboneElement | IIN (BIN) number
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:pbm-member-id | S | 0..1 | BackboneElement | PBM Member ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
order | Σ | 0..1 | positiveInt | Relative order of the coverage
network | Σ | 0..1 | string | Insurer network
costToBeneficiary |  | 0..* | BackboneElement | Patient payments for services/products
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
value[x] | Σ | 1..1 |  | The amount or percentage due from the beneficiary
valueQuantity |  |  | Quantity(SimpleQuantity) |
valueMoney |  |  | Money |
exception |  | 0..* | BackboneElement | Exceptions for patient payments
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | 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.
period | Σ | 0..1 | Period | The effective period of the exception
subrogation |  | 0..1 | boolean | Reimbursement to insurer
contract |  | 0..* | Reference(Contract) | Contract details
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
identifier | Σ | 0..* | Identifier | Member identifier
subscriberId | Σ | 0..1 | string | Health Plan Subscriber ID
payor | Σ | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy
class |  | 0..* | (Slice Definition) | Pharmacy coverage identifiers Slice: Unordered, Open by value:type
class:bin |  | 0..1 | BackboneElement | IIN (BIN) number
class:pcn |  | 0..1 | BackboneElement | Processor Control Number (PCN)
class:rxgroup-id |  | 0..1 | BackboneElement | Pharmacy Benefit Group ID
class:pbm-member-id |  | 0..1 | BackboneElement | PBM Member ID
Documentation for this format

This structure is derived from Coverage

Summary

Mandatory: 0 element (4 nested mandatory elements)
Must-Support: 8 elements

Slices

This structure defines the following Slices:

- The element Coverage.class is sliced based on the value of value:type

Differential View

This structure is derived from Coverage

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
identifier | S | 0..* | Identifier | Member identifier
subscriberId | S | 0..1 | string | Health Plan Subscriber ID
payor | S | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy
class | S | 0..* | (Slice Definition) | Pharmacy coverage identifiers Slice: Unordered, Open by value:type
class:All Slices |  |  |  | Content/Rules for all slices
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes
class:bin | S | 0..1 | BackboneElement | IIN (BIN) number
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin
class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN)
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn
class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup
class:pbm-member-id | S | 0..1 | BackboneElement | PBM Member ID
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
id | Σ | 0..1 | string | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language.
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ | 0..* | Identifier | Member identifier
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | 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.
policyHolder | Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy
subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy
subscriberId | S Σ | 0..1 | string | Health Plan Subscriber ID
beneficiary | Σ | 1..1 | Reference(Patient) | Plan beneficiary
dependent | Σ | 0..1 | string | Dependent number
relationship |  | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
period | Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy
class | S | 0..* | (Slice Definition) | Pharmacy coverage identifiers Slice: Unordered, Open by value:type
class:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:bin | S | 0..1 | BackboneElement | IIN (BIN) number
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:pbm-member-id | S | 0..1 | BackboneElement | PBM Member ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
order | Σ | 0..1 | positiveInt | Relative order of the coverage
network | Σ | 0..1 | string | Insurer network
costToBeneficiary |  | 0..* | BackboneElement | Patient payments for services/products
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
value[x] | Σ | 1..1 |  | The amount or percentage due from the beneficiary
valueQuantity |  |  | Quantity(SimpleQuantity) |
valueMoney |  |  | Money |
exception |  | 0..* | BackboneElement | Exceptions for patient payments
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | 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.
period | Σ | 0..1 | Period | The effective period of the exception
subrogation |  | 0..1 | boolean | Reimbursement to insurer
contract |  | 0..* | Reference(Contract) | Contract details
Documentation for this format

Other representations of profile: Schematron

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Coverage.language | preferred | CommonLanguages Max Binding: AllLanguages
Coverage.status | required | FinancialResourceStatusCodes
Coverage.type | preferred | CoverageTypeAndSelf-PayCodes
Coverage.relationship | extensible | SubscriberRelationshipCodes
Coverage.class.type | extensible | CoverageClassCodes
Coverage.class:bin.type | extensible | Pattern: rxbin
Coverage.class:pcn.type | extensible | Pattern: rxpcn
Coverage.class:rxgroup-id.type | extensible | Pattern: rxgroup
Coverage.class:pbm-member-id.type | extensible | Pattern: rxid
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes

#### Constraints

Id | Path | Details | Requirements
dom-2 | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | 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 | 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 | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | Coverage | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | Coverage.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.policyHolder | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.subscriber | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.subscriberId | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.beneficiary | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.dependent | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.relationship | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.payor | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.class.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.class.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.class.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.class.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class.name | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:bin | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:bin.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.class:bin.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.class:bin.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.class:bin.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.class:bin.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:bin.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:bin.name | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:pcn | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:pcn.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.class:pcn.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.class:pcn.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.class:pcn.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.class:pcn.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:pcn.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:pcn.name | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:rxgroup-id | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:rxgroup-id.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.class:rxgroup-id.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.class:rxgroup-id.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.class:rxgroup-id.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.class:rxgroup-id.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:rxgroup-id.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:rxgroup-id.name | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:pbm-member-id | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:pbm-member-id.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.class:pbm-member-id.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.class:pbm-member-id.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.class:pbm-member-id.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.class:pbm-member-id.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:pbm-member-id.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.class:pbm-member-id.name | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.order | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.network | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.costToBeneficiary | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.costToBeneficiary.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.costToBeneficiary.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.costToBeneficiary.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.costToBeneficiary.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.costToBeneficiary.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.costToBeneficiary.value[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.costToBeneficiary.exception | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.costToBeneficiary.exception.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.costToBeneficiary.exception.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.costToBeneficiary.exception.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | Coverage.costToBeneficiary.exception.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | Coverage.costToBeneficiary.exception.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.costToBeneficiary.exception.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.subrogation | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | Coverage.contract | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |