AU Core Implementation Guide
0.1.0-draft - Draft Australia flag

This page is part of the AU Core Implementation Guide 0.1.0 Draft. It is based on AU Base 4.1.0. For a full list of available versions, see the Directory of published versions

Resource Profile: AU Core Coverage

Official URL: http://hl7.org.au/fhir/core/StructureDefinition/au-core-coverage Version: 0.1.0-draft
Standards status: Draft Maturity Level: 0 Computable Name: AUCoreCoverage

Copyright/Legal: HL7 Australia© 2018+; Licensed Under Creative Commons No Rights Reserved.

This profile sets minimum expectations for a Coverage resource to record, search, and fetch information about a patient’s public or private insurance coverage. It is based on the core Coverage resource and identifies the additional mandatory core elements, extensions, vocabularies and value sets that SHALL be present in the Coverage when conforming to this profile. It provides the floor for standards development for specific uses cases in an Australian context.

Usage scenarios

The following are supported usage scenarios for this profile:

  • Query for a patient’s insurance coverage
  • Record or update a patient’s insurance coverages

Profile specific implementation guidance

TBD

Usage:

Formal Views of Profile Content

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

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
au-core-cov-01: The coverage shall at least have a valid identifier or type
... identifier SC0..*Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumberAn identifier intended for computation
... status S1..1codeactive | cancelled | draft | entered-in-error
... type SC0..1CodeableConceptCoverage category such as medical or accident
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
... period S0..1PeriodCoverage start and end dates
... payor S1..*Reference(AU Core Organization | AU Core Patient | AU Core RelatedPerson)Issuer of the policy
... class S0..*BackboneElementAdditional coverage classifications
.... type S1..1CodeableConceptType of class such as 'group' or 'plan'
.... value S1..1stringValue associated with the type
.... name S0..1stringHuman readable description of the type and value

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
au-core-cov-01errorCoverageThe coverage shall at least have a valid identifier or type
: type.exists() or identifier.where(system.count() + value.count() >1).exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
au-core-cov-01: The coverage shall at least have a valid identifier or type
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SC0..*Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumberAn identifier intended for computation
... type SΣC0..1CodeableConceptCoverage 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.

... beneficiary SΣ1..1Reference(AU Core Patient)Plan beneficiary
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(AU Core Organization | AU Core Patient | AU Core RelatedPerson)Issuer of the policy
... class S0..*BackboneElementAdditional coverage classifications
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SΣ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

.... value SΣ1..1stringValue associated with the type
.... name SΣ0..1stringHuman readable description of the type and value

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes

Constraints

IdGradePath(s)DetailsRequirements
au-core-cov-01errorCoverageThe coverage shall at least have a valid identifier or type
: type.exists() or identifier.where(system.count() + value.count() >1).exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
au-core-cov-01: The coverage shall at least have a valid identifier or type
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SC0..*Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumberAn identifier intended for computation
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣC0..1CodeableConceptCoverage 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 Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId Σ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(AU Core Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(AU Core Organization | AU Core Patient | AU Core RelatedPerson)Issuer of the policy
... class S0..*BackboneElementAdditional coverage classifications
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SΣ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

.... value SΣ1..1stringValue associated with the type
.... name SΣ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

Differential View

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
au-core-cov-01: The coverage shall at least have a valid identifier or type
... identifier SC0..*Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumberAn identifier intended for computation
... status S1..1codeactive | cancelled | draft | entered-in-error
... type SC0..1CodeableConceptCoverage category such as medical or accident
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
... period S0..1PeriodCoverage start and end dates
... payor S1..*Reference(AU Core Organization | AU Core Patient | AU Core RelatedPerson)Issuer of the policy
... class S0..*BackboneElementAdditional coverage classifications
.... type S1..1CodeableConceptType of class such as 'group' or 'plan'
.... value S1..1stringValue associated with the type
.... name S0..1stringHuman readable description of the type and value

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
au-core-cov-01errorCoverageThe coverage shall at least have a valid identifier or type
: type.exists() or identifier.where(system.count() + value.count() >1).exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
au-core-cov-01: The coverage shall at least have a valid identifier or type
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SC0..*Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumberAn identifier intended for computation
... type SΣC0..1CodeableConceptCoverage 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.

... beneficiary SΣ1..1Reference(AU Core Patient)Plan beneficiary
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(AU Core Organization | AU Core Patient | AU Core RelatedPerson)Issuer of the policy
... class S0..*BackboneElementAdditional coverage classifications
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SΣ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

.... value SΣ1..1stringValue associated with the type
.... name SΣ0..1stringHuman readable description of the type and value

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes

Constraints

IdGradePath(s)DetailsRequirements
au-core-cov-01errorCoverageThe coverage shall at least have a valid identifier or type
: type.exists() or identifier.where(system.count() + value.count() >1).exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
au-core-cov-01: The coverage shall at least have a valid identifier or type
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SC0..*Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumberAn identifier intended for computation
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣC0..1CodeableConceptCoverage 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 Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId Σ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(AU Core Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(AU Core Organization | AU Core Patient | AU Core RelatedPerson)Issuer of the policy
... class S0..*BackboneElementAdditional coverage classifications
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SΣ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

.... value SΣ1..1stringValue associated with the type
.... name SΣ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Below is an overview of the mandatory and optional search parameters. FHIR search operations and the syntax used to describe the interactions is described here.

Name Type Conformance Description Path
TBD TBD TBD TBD TBD

Mandatory Search Parameters

The following search parameters and search parameter combinations SHALL be supported:

Optional Search Parameters

The following search parameters and search parameter combinations SHOULD be supported: