AU Base Implementation Guide
6.0.0-draft - Draft

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## Resource Profile: AU Base Coverage

Official URL: http://hl7.org.au/fhir/StructureDefinition/au-coverage | Version: 6.0.0-draft
Standards status: Trial-use | Maturity Level: 0 | Computable Name: AUBaseCoverage
Copyright/Legal: HL7 Australia© 2018+; Licensed Under Creative Commons No Rights Reserved.

This profile defines a coverage structure that localises core concepts, including terminology, for use in an Australian context. The purpose of this profile is to provide national level agreement on core localised concepts. This profile does not force conformance to core localised concepts. It enables implementers and modellers to make their own rules, i.e. profiling, about how to support these concepts for specific implementation needs.

### Usage Notes

Profile specific implementation guidance:

- See each Identifier profile page for guidance related to that identifier type.
- When populating the type:
  - Medicare coverage SHOULD be represented by sending the V3 Value SetActCoverageTypeCode code “PUBLICPOL”
  - DVA coverage SHOULD be represented by sending the V3 Value SetActCoverageTypeCode code “VET”
  - Private health insurance coverage SHOULD be represented by sending the V3 Value SetActCoverageTypeCode code “HIP”
  - Workcover coverage SHOULD be represented by sending the V3 Value SetActCoverageTypeCode code “WCBPOL”
  - Motor Accident coverage SHOULD be represented by sending the V3 Value SetActCoverageTypeCode code “AUTOPOL”
  - Private (self funded) coverage SHOULD be represented by sending the Coverage SelfPay Codes code “pay”
  - Concession coverage, for example Health Care Card or Pensioner Concession Card, SHOULD be represented by sending the Coverage SelfPay Codes code “payconc”

Usages:

- Examples for this Profile: Coverage/dva and Coverage/private

Changes since version 5.0.0:

- New Content

### Formal Views of Profile Content

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

- Differential Table
- Key Elements Table
- Snapshot Table
- Statistics/References
- All

This structure is derived from Coverage

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
identifier |  | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber, AUPensionerConcessionCardNumber, AUCwlthSeniorsHealthCardNumber, AUHealthCareCardNumber | Business Identifier for the coverage
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber, AUPensionerConcessionCardNumber, AUCwlthSeniorsHealthCardNumber, AUHealthCareCardNumber | Business Identifier for the coverage
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
beneficiary | Σ | 1..1 | Reference(Patient) | Plan beneficiary
payor | Σ | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Coverage.status | required | FinancialResourceStatusCodes `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard

#### Constraints

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 Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
id | Σ | 0..1 | id | 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): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber, AUPensionerConcessionCardNumber, AUCwlthSeniorsHealthCardNumber, AUHealthCareCardNumber | Business Identifier for the coverage
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 | Σ | 0..1 | string | ID assigned to the subscriber
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 | Σ | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy
class |  | 0..* | BackboneElement | Additional coverage classifications
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.
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

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Coverage.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Coverage.status | required | FinancialResourceStatusCodes `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard
Coverage.type | preferred | CoverageTypeAndSelf-PayCodes `http://hl7.org/fhir/ValueSet/coverage-type` From the FHIR Standard
Coverage.relationship | extensible | SubscriberRelationshipCodes `http://hl7.org/fhir/ValueSet/subscriber-relationship` From the FHIR Standard
Coverage.class.type | extensible | CoverageClassCodes `http://hl7.org/fhir/ValueSet/coverage-class` From the FHIR Standard
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes `http://hl7.org/fhir/ValueSet/coverage-copay-type` From the FHIR Standard
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes `http://hl7.org/fhir/ValueSet/coverage-financial-exception` From the FHIR Standard

#### Constraints

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

Summary

Maturity: 0

Differential View

This structure is derived from Coverage

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
identifier |  | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber, AUPensionerConcessionCardNumber, AUCwlthSeniorsHealthCardNumber, AUHealthCareCardNumber | Business Identifier for the coverage
Documentation for this format

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber, AUPensionerConcessionCardNumber, AUCwlthSeniorsHealthCardNumber, AUHealthCareCardNumber | Business Identifier for the coverage
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
beneficiary | Σ | 1..1 | Reference(Patient) | Plan beneficiary
payor | Σ | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Coverage.status | required | FinancialResourceStatusCodes `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard

#### Constraints

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 Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
id | Σ | 0..1 | id | 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): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber, AUPensionerConcessionCardNumber, AUCwlthSeniorsHealthCardNumber, AUHealthCareCardNumber | Business Identifier for the coverage
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 | Σ | 0..1 | string | ID assigned to the subscriber
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 | Σ | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy
class |  | 0..* | BackboneElement | Additional coverage classifications
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.
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

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Coverage.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Coverage.status | required | FinancialResourceStatusCodes `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard
Coverage.type | preferred | CoverageTypeAndSelf-PayCodes `http://hl7.org/fhir/ValueSet/coverage-type` From the FHIR Standard
Coverage.relationship | extensible | SubscriberRelationshipCodes `http://hl7.org/fhir/ValueSet/subscriber-relationship` From the FHIR Standard
Coverage.class.type | extensible | CoverageClassCodes `http://hl7.org/fhir/ValueSet/coverage-class` From the FHIR Standard
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes `http://hl7.org/fhir/ValueSet/coverage-copay-type` From the FHIR Standard
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes `http://hl7.org/fhir/ValueSet/coverage-financial-exception` From the FHIR Standard

#### Constraints

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

Summary

Maturity: 0

Other representations of profile: CSV, Excel, Schematron