AU eRequesting Implementation Guide
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## Resource Profile: AU eRequesting Coverage

Official URL: http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-coverage | Version: 0.3.0-preview
Standards status: Draft | Maturity Level: 0 | Computable Name: AUeRequestingCoverage
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License. HL7 Australia© 2024+; Licensed Under Creative Commons No Rights Reserved.

This profile sets minimum expectations for a Coverage resource that is used to record, search, and fetch information about insurance or medical plan or a payment agreement for a patient. It is based on the AU Base Coverage and identifies the additional constraints, extensions, vocabularies and value sets that SHALL be present in the Coverage when conforming to this profile.

Usage:

- Refer to this Resource Profile: AU eRequesting Diagnostic Request
- CapabilityStatements using this Resource Profile: AU eRequesting Filler CapabilityStatement, AU eRequesting Patient CapabilityStatement, AU eRequesting Placer CapabilityStatement and AU eRequesting Server CapabilityStatement

### Formal Views of Profile Content

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

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

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  | 0..* | AUBaseCoverage | Insurance or medical plan or a payment agreement dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children
type | Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: AU eRequesting Coverage Type and Self-Pay Codes (preferred)
Additional Bindings | Purpose
AU eRequesting Coverage Type and Self-Pay Codes | Min Binding
ele-1: All FHIR elements must have a @value or children
beneficiary | Σ | 1..1 | Reference(Patient) | Plan beneficiary ele-1: All FHIR elements must have a @value or children
payor | Σ | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy ele-1: All FHIR elements must have a @value or children
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
Coverage.type | preferred | AUeRequestingCoverageTypeAndSelf-PayCodes `http://terminology.hl7.org.au/ValueSet/au-erequesting-coverage-type` from this IG

This structure is derived from AUBaseCoverage

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  |  | AUBaseCoverage |
type |  | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: AU eRequesting Coverage Type and Self-Pay Codes (preferred)
Additional Bindings | Purpose
AU eRequesting Coverage Type and Self-Pay Codes | Min Binding
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Coverage.type | preferred | AUeRequestingCoverageTypeAndSelf-PayCodes `http://terminology.hl7.org.au/ValueSet/au-erequesting-coverage-type` from this IG

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  | 0..* | AUBaseCoverage | 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
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: AU eRequesting Coverage Type and Self-Pay Codes (preferred)
Additional Bindings | Purpose
AU eRequesting Coverage Type and Self-Pay Codes | Min Binding
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 | AUeRequestingCoverageTypeAndSelf-PayCodes `http://terminology.hl7.org.au/ValueSet/au-erequesting-coverage-type` from this IG
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

This structure is derived from AUBaseCoverage

Summary

Maturity: 0

Key Elements View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  | 0..* | AUBaseCoverage | Insurance or medical plan or a payment agreement dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children
type | Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: AU eRequesting Coverage Type and Self-Pay Codes (preferred)
Additional Bindings | Purpose
AU eRequesting Coverage Type and Self-Pay Codes | Min Binding
ele-1: All FHIR elements must have a @value or children
beneficiary | Σ | 1..1 | Reference(Patient) | Plan beneficiary ele-1: All FHIR elements must have a @value or children
payor | Σ | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy ele-1: All FHIR elements must have a @value or children
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
Coverage.type | preferred | AUeRequestingCoverageTypeAndSelf-PayCodes `http://terminology.hl7.org.au/ValueSet/au-erequesting-coverage-type` from this IG

Differential View

This structure is derived from AUBaseCoverage

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  |  | AUBaseCoverage |
type |  | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: AU eRequesting Coverage Type and Self-Pay Codes (preferred)
Additional Bindings | Purpose
AU eRequesting Coverage Type and Self-Pay Codes | Min Binding
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Coverage.type | preferred | AUeRequestingCoverageTypeAndSelf-PayCodes `http://terminology.hl7.org.au/ValueSet/au-erequesting-coverage-type` from this IG

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  | 0..* | AUBaseCoverage | 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
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: AU eRequesting Coverage Type and Self-Pay Codes (preferred)
Additional Bindings | Purpose
AU eRequesting Coverage Type and Self-Pay Codes | Min Binding
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 | AUeRequestingCoverageTypeAndSelf-PayCodes `http://terminology.hl7.org.au/ValueSet/au-erequesting-coverage-type` from this IG
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

This structure is derived from AUBaseCoverage

Summary

Maturity: 0

Other representations of profile: CSV, Excel, Schematron

### Notes:

Below is an overview of the mandatory and optional search parameters and combined search parameters. See the AU eRequesting CapabilityStatements for a complete list of supported RESTful interactions for this IG.

FHIR search operations are described here and the syntax used to describe AU eRequesting interactions is defined here.

Any search parameter defined in FHIR may be 'allowed' by the system unless explicitly marked as "SHALL NOT".

Parameter(s) | Server Conformance | Placer Conformance | Filler Conformance | Patient Conformance | Type(s) | Requirements (when used alone or in combination)
--- | --- | --- | --- | --- | --- | ---
_id | SHALL | - | - | - | `token` |

#### Search Parameters:

The following search parameters and search parameter combinations are supported. Conformance obligations are detailed in the table above.

1. `_id` search parameter

   `GET [base]/Coverage?_id=[id]`

   Example:

   1. GET [base]/Coverage?_id=10045786

Implementation Notes: Fetches a bundle with the requested Coverage, instead of just the resource itself, and allows for the inclusion of additional search parameters such as _include, _revinclude, or _lastUpdated (how to search by id of the resource)