AU Core Implementation Guide
0.2.1-preview - Preview Australia flag

This page is part of the Australian Core IG (v0.2.1-preview: AU Core) based on FHIR R4. For a full list of available versions, see the Directory of published versions

Resource Profile: AUCoreCoverage - Detailed Descriptions

Page standards status: Draft Maturity Level: 0

Definitions for the au-core-coverage resource profile.

Guidance on how to interpret the contents of this table can be found here.

1. Coverage
InvariantsDefined on this element
au-core-cov-01: The coverage shall at least have a valid identifier or type (: type.exists() or identifier.where(system.count() + value.count() >1).exists())
2. Coverage.identifier
NoteThis is a business identifier, not a resource identifier (see discussion)
Control This element is affected by the following invariants: au-core-cov-01, ele-1
Must Supporttrue
SlicingThis element introduces a set of slices on Coverage.identifier. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ type
3. Coverage.identifier:insurancemembernumber
SliceNameinsurancemembernumber
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier(AUInsuranceMemberNumber)
Must Supporttrue
4. Coverage.identifier:medicare
SliceNamemedicare
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier(AUMedicareCardNumber)
Must Supporttrue
5. Coverage.identifier:dva
SliceNamedva
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier(AUDVANumber)
Must Supporttrue
6. Coverage.status
Must Supporttrue
7. Coverage.type
Control This element is affected by the following invariants: au-core-cov-01
BindingThe codes SHALL be taken from Coverage Type and Self-Pay Codes - AU Extended; other codes may be used where these codes are not suitableThe codes SHOULD be taken from Coverage Type and Self-Pay Codes - AU Extended
Must Supporttrue
8. Coverage.beneficiary
TypeReference(AUCorePatient|Patient)
Must Supporttrue
9. Coverage.relationship
Must Supporttrue
10. Coverage.period
Must Supporttrue
11. Coverage.payor
TypeReference(AUCoreOrganization|AUCorePatient|AUCoreRelatedPerson|Organization|Patient|RelatedPerson)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
12. Coverage.class
Must Supporttrue
13. Coverage.class.type
Must Supporttrue
14. Coverage.class.value
Must Supporttrue
15. Coverage.class.name
Must Supporttrue

Guidance on how to interpret the contents of this table can be found here.

1. Coverage
Definition

Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.

Control0..*
Summaryfalse
Comments

The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.

InvariantsDefined on this element
au-core-cov-01: The coverage shall at least have a valid identifier or type (: type.exists() or identifier.where(system.count() + value.count() >1).exists())
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty())
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 (: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (: contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (: text.`div`.exists())
2. Coverage.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Control0..1
Typeuri
Is Modifiertrue
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
3. Coverage.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
4. Coverage.identifier
Definition

An identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers.

A unique identifier assigned to this coverage.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..* This element is affected by the following invariants: ele-1, au-core-cov-01
TypeIdentifier(Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Requirements

Allows coverages to be distinguished and referenced.

Comments

The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Coverage.identifier. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ type
5. Coverage.identifier:insurancemembernumber
SliceNameinsurancemembernumber
Definition

Insurance member number assigned to an individual by an insurer as their unique member number. It is typically displayed on their insurance card and an individual will not have more than one member number per insurer. This identifier should not be confused with an insurance policy number.

A unique identifier assigned to this coverage.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1* This element is affected by the following invariants: ele-1
TypeIdentifier(AUInsuranceMemberNumber)
Must Supporttrue
Requirements

Allows coverages to be distinguished and referenced.

Comments

The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
6. Coverage.identifier:medicare
SliceNamemedicare
Definition

Medicare card number as either the the 10 digit Medicare card number or the 11 digit number (includes the individual reference number (IRN)). A Medicare card is provided to individuals who are enrolled in Medicare.

A unique identifier assigned to this coverage.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1* This element is affected by the following invariants: ele-1
TypeIdentifier(AUMedicareCardNumber)
Must Supporttrue
Requirements

Allows coverages to be distinguished and referenced.

Comments

The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
7. Coverage.identifier:dva
SliceNamedva
Definition

Department of Veterans’ Affairs (DVA) file number displayed on a Veteran Card.

A unique identifier assigned to this coverage.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1* This element is affected by the following invariants: ele-1
TypeIdentifier(AUDVANumber)
Must Supporttrue
Requirements

Allows coverages to be distinguished and referenced.

Comments

The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
8. Coverage.status
Definition

The status of the resource instance.

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodes

A code specifying the state of the resource instance.

Typecode
Is Modifiertrue
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Comments

This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
9. Coverage.type
Definition

The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.

Control0..1 This element is affected by the following invariants: au-core-cov-01
BindingThe codes SHALL be taken from Coverage Type and Self-Pay Codes - AU Extended; other codes may be used where these codes are not suitableThe codes SHOULD be taken from CoverageTypeAndSelf-PayCodes
TypeCodeableConcept
Must Supporttrue
Summarytrue
Requirements

The order of application of coverages is dependent on the types of coverage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
10. Coverage.beneficiary
Definition

The party who benefits from the insurance coverage; the patient when products and/or services are provided.

Control1..1
TypeReference(AUCorePatient|Patient)
Must Supporttrue
Summarytrue
Requirements

This is the party who receives treatment for which the costs are reimbursed under the coverage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
11. Coverage.relationship
Definition

The relationship of beneficiary (patient) to the subscriber.

Control0..1
BindingThe codes SHALL be taken from SubscriberRelationshipCodes; other codes may be used where these codes are not suitable

The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

TypeCodeableConcept
Must Supporttrue
Summaryfalse
Requirements

To determine relationship between the patient and the subscriber to determine coordination of benefits.

Comments

Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
12. Coverage.period
Definition

Time period during which the coverage is in force. A missing start date indicates the start date isn't known, a missing end date means the coverage is continuing to be in force.

Control0..1
TypePeriod
Must Supporttrue
Summarytrue
Requirements

Some insurers require the submission of the coverage term.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
13. Coverage.payor
Definition

The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.

Control1..*
TypeReference(AUCoreOrganization|AUCorePatient|AUCoreRelatedPerson|Organization|Patient|RelatedPerson)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Requirements

Need to identify the issuer to target for claim processing and for coordination of benefit processing.

Comments

May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
14. Coverage.class
Definition

A suite of underwriter specific classifiers.

Control0..*
TypeBackboneElement
Must Supporttrue
Summaryfalse
Requirements

The codes provided on the health card which identify or confirm the specific policy for the insurer.

Comments

For example may be used to identify a class of coverage or employer group, Policy, Plan.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
15. Coverage.class.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
16. Coverage.class.type
Definition

The type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan.

Control1..1
BindingThe codes SHALL be taken from CoverageClassCodes; other codes may be used where these codes are not suitable

The policy classifications, eg. Group, Plan, Class, etc.

TypeCodeableConcept
Must Supporttrue
Summarytrue
Requirements

The insurer issued label for a specific health card value.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
17. Coverage.class.value
Definition

The alphanumeric string value associated with the insurer issued label.

Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

The insurer issued label and value are necessary to identify the specific policy.

Comments

For example, the Group or Plan number.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
18. Coverage.class.name
Definition

A short description for the class.

Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Used to provide a meaningful description in correspondence to the patient.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be found here.

1. Coverage
Definition

Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.

Control0..*
Summaryfalse
Comments

The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.

2. Coverage.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typeid
Summarytrue
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

3. Coverage.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Control0..1
TypeMeta
Summarytrue
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
4. Coverage.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Control0..1
Typeuri
Is Modifiertrue
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
5. Coverage.language
Definition

The base language in which the resource is written.

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages A human language
Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
6. Coverage.text
Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
TypeNarrative
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
7. Coverage.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Control0..*
TypeResource
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

8. Coverage.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Summaryfalse
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
9. Coverage.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
10. Coverage.identifier
Definition

An identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..* This element is affected by the following invariants: ele-1, au-core-cov-01
TypeIdentifier(Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Requirements

Allows coverages to be distinguished and referenced.

Comments

The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Coverage.identifier. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ type
11. Coverage.identifier:insurancemembernumber
SliceNameinsurancemembernumber
Definition

Insurance member number assigned to an individual by an insurer as their unique member number. It is typically displayed on their insurance card and an individual will not have more than one member number per insurer. This identifier should not be confused with an insurance policy number.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1 This element is affected by the following invariants: ele-1
TypeIdentifier(AUInsuranceMemberNumber)
Must Supporttrue
Requirements

Allows coverages to be distinguished and referenced.

Comments

The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
12. Coverage.identifier:medicare
SliceNamemedicare
Definition

Medicare card number as either the the 10 digit Medicare card number or the 11 digit number (includes the individual reference number (IRN)). A Medicare card is provided to individuals who are enrolled in Medicare.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1 This element is affected by the following invariants: ele-1
TypeIdentifier(AUMedicareCardNumber)
Must Supporttrue
Requirements

Allows coverages to be distinguished and referenced.

Comments

The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
13. Coverage.identifier:dva
SliceNamedva
Definition

Department of Veterans’ Affairs (DVA) file number displayed on a Veteran Card.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1 This element is affected by the following invariants: ele-1
TypeIdentifier(AUDVANumber)
Must Supporttrue
Requirements

Allows coverages to be distinguished and referenced.

Comments

The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
14. Coverage.status
Definition

The status of the resource instance.

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodes A code specifying the state of the resource instance
Typecode
Is Modifiertrue
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Comments

This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
15. Coverage.type
Definition

The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.

Control0..1 This element is affected by the following invariants: au-core-cov-01
BindingThe codes SHALL be taken from Coverage Type and Self-Pay Codes - AU Extended; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Summarytrue
Requirements

The order of application of coverages is dependent on the types of coverage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
16. Coverage.policyHolder
Definition

The party who 'owns' the insurance policy.

Control0..1
TypeReference(Patient|RelatedPerson|Organization)
Summarytrue
Requirements

This provides employer information in the case of Worker's Compensation and other policies.

Comments

For example: may be an individual, corporation or the subscriber's employer.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
17. Coverage.subscriber
Definition

The party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due.

Control0..1
TypeReference(Patient|RelatedPerson)
Summarytrue
Requirements

This is the party who is entitled to the benfits under the policy.

Comments

May be self or a parent in the case of dependants.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
18. Coverage.subscriberId
Definition

The insurer assigned ID for the Subscriber.

Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

The insurer requires this identifier on correspondance and claims (digital and otherwise).

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
19. Coverage.beneficiary
Definition

The party who benefits from the insurance coverage; the patient when products and/or services are provided.

Control1..1
TypeReference(AUCorePatient)
Must Supporttrue
Summarytrue
Requirements

This is the party who receives treatment for which the costs are reimbursed under the coverage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
20. Coverage.dependent
Definition

A unique identifier for a dependent under the coverage.

Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

For some coverages a single identifier is issued to the Subscriber and then a unique dependent number is issued to each beneficiary.

Comments

Periodically the member number is constructed from the subscriberId and the dependant number.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
21. Coverage.relationship
Definition

The relationship of beneficiary (patient) to the subscriber.

Control0..1
BindingThe codes SHALL be taken from SubscriberRelationshipCodes; other codes may be used where these codes are not suitable The relationship between the Subscriber and the Beneficiary (insured/covered party/patient)
TypeCodeableConcept
Must Supporttrue
Summaryfalse
Requirements

To determine relationship between the patient and the subscriber to determine coordination of benefits.

Comments

Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
22. Coverage.period
Definition

Time period during which the coverage is in force. A missing start date indicates the start date isn't known, a missing end date means the coverage is continuing to be in force.

Control0..1
TypePeriod
Must Supporttrue
Summarytrue
Requirements

Some insurers require the submission of the coverage term.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
23. Coverage.payor
Definition

The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.

Control1..*
TypeReference(AUCoreOrganization|AUCorePatient|AUCoreRelatedPerson)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Requirements

Need to identify the issuer to target for claim processing and for coordination of benefit processing.

Comments

May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
24. Coverage.class
Definition

A suite of underwriter specific classifiers.

Control0..*
TypeBackboneElement
Must Supporttrue
Summaryfalse
Requirements

The codes provided on the health card which identify or confirm the specific policy for the insurer.

Comments

For example may be used to identify a class of coverage or employer group, Policy, Plan.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
25. Coverage.class.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
Summaryfalse
26. Coverage.class.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Summaryfalse
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
27. Coverage.class.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
28. Coverage.class.type
Definition

The type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan.

Control1..1
BindingThe codes SHALL be taken from CoverageClassCodes; other codes may be used where these codes are not suitable The policy classifications, eg. Group, Plan, Class, etc
TypeCodeableConcept
Must Supporttrue
Summarytrue
Requirements

The insurer issued label for a specific health card value.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
29. Coverage.class.value
Definition

The alphanumeric string value associated with the insurer issued label.

Control1..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

The insurer issued label and value are necessary to identify the specific policy.

Comments

For example, the Group or Plan number.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
30. Coverage.class.name
Definition

A short description for the class.

Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Used to provide a meaningful description in correspondence to the patient.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
31. Coverage.order
Definition

The order of applicability of this coverage relative to other coverages which are currently in force. Note, there may be gaps in the numbering and this does not imply primary, secondary etc. as the specific positioning of coverages depends upon the episode of care.

Control0..1
TypepositiveInt
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Used in managing the coordination of benefits.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
32. Coverage.network
Definition

The insurer-specific identifier for the insurer-defined network of providers to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply.

Control0..1
Typestring
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Used in referral for treatment and in claims processing.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
33. Coverage.costToBeneficiary
Definition

A suite of codes indicating the cost category and associated amount which have been detailed in the policy and may have been included on the health card.

Control0..*
TypeBackboneElement
Summaryfalse
Requirements

Required by providers to manage financial transaction with the patient.

Alternate NamesCoPay, Deductible, Exceptions
Comments

For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
34. Coverage.costToBeneficiary.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
Summaryfalse
35. Coverage.costToBeneficiary.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Summaryfalse
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
36. Coverage.costToBeneficiary.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
37. Coverage.costToBeneficiary.type
Definition

The category of patient centric costs associated with treatment.

Control0..1
BindingThe codes SHALL be taken from CoverageCopayTypeCodes; other codes may be used where these codes are not suitable The types of services to which patient copayments are specified
TypeCodeableConcept
Summarytrue
Requirements

Needed to identify the category associated with the amount for the patient.

Comments

For example visit, specialist visits, emergency, inpatient care, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
38. Coverage.costToBeneficiary.value[x]
Definition

The amount due from the patient for the cost category.

Control1..1
TypeChoice of: Quantity(SimpleQuantity), Money
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Requirements

Needed to identify the amount for the patient associated with the category.

Comments

Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
39. Coverage.costToBeneficiary.exception
Definition

A suite of codes indicating exceptions or reductions to patient costs and their effective periods.

Control0..*
TypeBackboneElement
Summaryfalse
Requirements

Required by providers to manage financial transaction with the patient.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
40. Coverage.costToBeneficiary.exception.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
Summaryfalse
41. Coverage.costToBeneficiary.exception.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Summaryfalse
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
42. Coverage.costToBeneficiary.exception.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
43. Coverage.costToBeneficiary.exception.type
Definition

The code for the specific exception.

Control1..1
BindingFor example codes, see ExampleCoverageFinancialExceptionCodes The types of exceptions from the part or full value of financial obligations such as copays
TypeCodeableConcept
Summarytrue
Requirements

Needed to identify the exception associated with the amount for the patient.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
44. Coverage.costToBeneficiary.exception.period
Definition

The timeframe during when the exception is in force.

Control0..1
TypePeriod
Summarytrue
Requirements

Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
45. Coverage.subrogation
Definition

When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs.

Control0..1
Typeboolean
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

See definition for when to be used.

Comments

Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
46. Coverage.contract
Definition

The policy(s) which constitute this insurance coverage.

Control0..*
TypeReference(Contract)
Summaryfalse
Requirements

To reference the legally binding contract between the policy holder and the insurer.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))