AU eRequesting Implementation Guide
1.0.0 - Working Standard

AU eRequesting Implementation Guide - Downloaded Version 1.0.0 See the Directory of published versions

## Resource Profile: AU eRequesting Coverage

Official URL: http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-coverage | Version: 1.0.0
Standards status: Trial-use | Maturity Level: 1 | 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 profile and identifies the additional constraints, extensions, vocabularies and value sets that SHALL be present in the Coverage when conforming to this profile.

### Profile Specific Implementation Guidance

- See guidance on the construction of identifiers in each Identifier profile and the section on Business Identifiers in AU Base.
- See guidance on populating `Coverage.type` in AU Base Coverage Profile Specific Implementation Guidance.
- When using one of the below Coverage types, at least one of the corresponding identifiers SHOULD be populated:

Coverage | Coverage.type | Coverage.identifier
--- | --- | ---
Medicare | PUBLICPOL | AU Medicare Card Number
Department of Veterans Affairs (DVA) | VET | AU DVA Number
Concession | payconc | AU Pensioner Concession Card Number, AU Commonwealth Seniors Health Card Number, AU Health Care Card Number
Private health insurance | HIP | AU Insurance Member Number
Private (self funded) | pay | N/A

Usages:

- Refer to this Profile: AU eRequesting Diagnostic Request
- Examples for this Profile: Coverage/coverage-concession and Coverage/coverage-dva
- CapabilityStatements using this Profile: AU eRequesting Filler CapabilityStatement, AU eRequesting Patient CapabilityStatement, AU eRequesting Placer CapabilityStatement and AU eRequesting Server CapabilityStatement

You can also check for usages in the FHIR IG Statistics

### 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 Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage |  | 0..* | AUBaseCoverage | 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 | SO Σ | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber, AUPensionerConcessionCardNumber, AUCwlthSeniorsHealthCardNumber, AUHealthCareCardNumber | Business Identifier for the coverage
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
status | ?!SO Σ | 1..1 | code | Status of the coverage Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
type | SO Σ | 1..1 | CodeableConcept | Coverage category such as medical or accident Binding: Coverage Type and Self-Pay Codes - AU Extended (preferred)
Additional Bindings | Purpose
AU eRequesting Coverage Type and Self-Pay Codes | Min Binding
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
beneficiary | SO Σ | 1..1 | Reference(AU eRequesting Patient) | Plan beneficiary
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
payor | SO Σ | 1..* | Reference(AU eRequesting Patient | AU eRequesting Organization | AU Core RelatedPerson) | Issuer of the policy
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
Coverage.type | Base | preferred | Coverage Type and Self-Pay Codes - AU Extended | 📦6.0.0 | AU Base Implementation Guide v6.0

#### Constraints

Id | Grade | Path(s) | Description | Expression
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 AUBaseCoverage

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage |  | 0..* | AUBaseCoverage | Insurance or medical plan or a payment agreement
identifier | SO | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber, AUPensionerConcessionCardNumber, AUCwlthSeniorsHealthCardNumber, AUHealthCareCardNumber | Business Identifier for the coverage
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
status | SO | 1..1 | code | Status of the coverage Fixed Value: active
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
type | SO | 1..1 | CodeableConcept | Coverage category such as medical or accident Binding: Coverage Type and Self-Pay Codes - AU Extended (preferred)
Additional Bindings | Purpose
AU eRequesting Coverage Type and Self-Pay Codes | Min Binding
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
beneficiary | SO | 1..1 | Reference(AU eRequesting Patient) | Plan beneficiary
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
payor | SO | 1..* | Reference(AU eRequesting Patient | AU eRequesting Organization | AU Core RelatedPerson) | Issuer of the policy
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Coverage.type | Base | preferred | Coverage Type and Self-Pay Codes - AU Extended | 📦6.0.0 | AU Base Implementation Guide v6.0

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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 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 | SO Σ | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber, AUPensionerConcessionCardNumber, AUCwlthSeniorsHealthCardNumber, AUHealthCareCardNumber | Business Identifier for the coverage
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
status | ?!SO Σ | 1..1 | code | Status of the coverage Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
type | SO Σ | 1..1 | CodeableConcept | Coverage category such as medical or accident Binding: Coverage Type and Self-Pay Codes - AU Extended (preferred)
Additional Bindings | Purpose
AU eRequesting Coverage Type and Self-Pay Codes | Min Binding
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
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 | SO Σ | 1..1 | Reference(AU eRequesting Patient) | Plan beneficiary
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
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 | SO Σ | 1..* | Reference(AU eRequesting Patient | AU eRequesting Organization | AU Core RelatedPerson) | Issuer of the policy
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
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 | Status | Usage | ValueSet | Version | Source
Coverage.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
Coverage.type | Base | preferred | Coverage Type and Self-Pay Codes - AU Extended | 📦6.0.0 | AU Base Implementation Guide v6.0
Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📍4.0.1 | FHIR Std.
Coverage.class.type | Base | extensible | Coverage Class Codes | 📍4.0.1 | FHIR Std.
Coverage.costToBeneficiary.​type | Base | extensible | Coverage Copay Type Codes | 📍4.0.1 | FHIR Std.
Coverage.costToBeneficiary.​exception.type | Base | example | Example Coverage Financial Exception Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
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 AUBaseCoverage

Summary

Mandatory: 1 element
Must-Support: 5 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

- AU eRequesting Patient (http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-patient)
- AU eRequesting Organization (http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-organization)
- AU Core RelatedPerson (http://hl7.org.au/fhir/core/StructureDefinition/au-core-relatedperson)

Maturity: 1

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage |  | 0..* | AUBaseCoverage | 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 | SO Σ | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber, AUPensionerConcessionCardNumber, AUCwlthSeniorsHealthCardNumber, AUHealthCareCardNumber | Business Identifier for the coverage
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
status | ?!SO Σ | 1..1 | code | Status of the coverage Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
type | SO Σ | 1..1 | CodeableConcept | Coverage category such as medical or accident Binding: Coverage Type and Self-Pay Codes - AU Extended (preferred)
Additional Bindings | Purpose
AU eRequesting Coverage Type and Self-Pay Codes | Min Binding
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
beneficiary | SO Σ | 1..1 | Reference(AU eRequesting Patient) | Plan beneficiary
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
payor | SO Σ | 1..* | Reference(AU eRequesting Patient | AU eRequesting Organization | AU Core RelatedPerson) | Issuer of the policy
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
Coverage.type | Base | preferred | Coverage Type and Self-Pay Codes - AU Extended | 📦6.0.0 | AU Base Implementation Guide v6.0

#### Constraints

Id | Grade | Path(s) | Description | Expression
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()`

Differential View

This structure is derived from AUBaseCoverage

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage |  | 0..* | AUBaseCoverage | Insurance or medical plan or a payment agreement
identifier | SO | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber, AUPensionerConcessionCardNumber, AUCwlthSeniorsHealthCardNumber, AUHealthCareCardNumber | Business Identifier for the coverage
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
status | SO | 1..1 | code | Status of the coverage Fixed Value: active
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
type | SO | 1..1 | CodeableConcept | Coverage category such as medical or accident Binding: Coverage Type and Self-Pay Codes - AU Extended (preferred)
Additional Bindings | Purpose
AU eRequesting Coverage Type and Self-Pay Codes | Min Binding
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
beneficiary | SO | 1..1 | Reference(AU eRequesting Patient) | Plan beneficiary
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
payor | SO | 1..* | Reference(AU eRequesting Patient | AU eRequesting Organization | AU Core RelatedPerson) | Issuer of the policy
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Coverage.type | Base | preferred | Coverage Type and Self-Pay Codes - AU Extended | 📦6.0.0 | AU Base Implementation Guide v6.0

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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 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 | SO Σ | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber, AUPensionerConcessionCardNumber, AUCwlthSeniorsHealthCardNumber, AUHealthCareCardNumber | Business Identifier for the coverage
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
status | ?!SO Σ | 1..1 | code | Status of the coverage Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
type | SO Σ | 1..1 | CodeableConcept | Coverage category such as medical or accident Binding: Coverage Type and Self-Pay Codes - AU Extended (preferred)
Additional Bindings | Purpose
AU eRequesting Coverage Type and Self-Pay Codes | Min Binding
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
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 | SO Σ | 1..1 | Reference(AU eRequesting Patient) | Plan beneficiary
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
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 | SO Σ | 1..* | Reference(AU eRequesting Patient | AU eRequesting Organization | AU Core RelatedPerson) | Issuer of the policy
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
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 | Status | Usage | ValueSet | Version | Source
Coverage.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
Coverage.type | Base | preferred | Coverage Type and Self-Pay Codes - AU Extended | 📦6.0.0 | AU Base Implementation Guide v6.0
Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📍4.0.1 | FHIR Std.
Coverage.class.type | Base | extensible | Coverage Class Codes | 📍4.0.1 | FHIR Std.
Coverage.costToBeneficiary.​type | Base | extensible | Coverage Copay Type Codes | 📍4.0.1 | FHIR Std.
Coverage.costToBeneficiary.​exception.type | Base | example | Example Coverage Financial Exception Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
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 AUBaseCoverage

Summary

Mandatory: 1 element
Must-Support: 5 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

- AU eRequesting Patient (http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-patient)
- AU eRequesting Organization (http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-organization)
- AU Core RelatedPerson (http://hl7.org.au/fhir/core/StructureDefinition/au-core-relatedperson)

Maturity: 1

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 | MAY | MAY | MAY | `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)