AU Core Implementation Guide
0.2.2-preview - Preview Australia flag

This page is part of the Australian Core IG (v0.2.2-preview: AU Core) based on FHIR R4. 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: 0.2.2-preview
Standards status: Draft Maturity Level: 0 Computable Name: AUCoreCoverage

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License. HL7 Australia© 2022+; 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 AU Base 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

Comparison with other national and international specifications

A resource conforming to this profile:

No equivalent International Patient Access or International Patient Summary profile.

Conformance in reverse is not guaranteed, i.e. a resource conforming to US Core MAY NOT conform to AU Core.

Profile specific implementation guidance

  • When querying if a patient is covered Coverage.status and Coverage.period are relevant. The coverage may not be active at the time of query but may have been applicable during the time of service or claim.
  • When supporting concession selfpay, two codings SHOULD be sent in Coverage.type, “pay” and “payconc”.

Usage:

Formal Views of Profile Content

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

This structure is derived from AUBaseCoverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*AUBaseCoverageInsurance or medical plan or a payment agreement
au-core-cov-01: The coverage shall at least have a valid identifier or type
... Slices for identifier SC0..*Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumberAn identifier intended for computation
Slice: Unordered, Open by pattern:type
.... identifier:insurancemembernumber S0..1AUInsuranceMemberNumberInsurance Member Number
.... identifier:medicare S0..1AUMedicareCardNumberMedicare Card Number
.... identifier:dva S0..1AUDVANumberDepartment of Veterans' Affairs (DVA) Number
... status S1..1codeactive | cancelled | draft | entered-in-error
... type SC0..1CodeableConceptCoverage category such as medical or accident
Binding: Coverage Type and Self-Pay Codes - AU Extended (extensible)
... 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

Terminology Bindings (Differential)

PathConformanceValueSet
Coverage.typeextensibleCoverageTypeAndSelfPayCodesAUExtended

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..*AUBaseCoverageInsurance 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
... Slices for identifier SC0..*Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumberAn identifier intended for computation
Slice: Unordered, Open by pattern:type
.... identifier:insurancemembernumber S0..1AUInsuranceMemberNumberInsurance Member Number
.... identifier:medicare S0..1AUMedicareCardNumberMedicare Card Number
.... identifier:dva S0..1AUDVANumberDepartment of Veterans' Affairs (DVA) Number
... type SΣC0..1CodeableConceptCoverage category such as medical or accident
Binding: Coverage Type and Self-Pay Codes - AU Extended (extensible)
... 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.typeextensibleCoverageTypeAndSelfPayCodesAUExtended
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..*AUBaseCoverageInsurance 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
... Slices for identifier SC0..*Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumberAn identifier intended for computation
Slice: Unordered, Open by pattern:type
.... identifier:insurancemembernumber S0..1AUInsuranceMemberNumberInsurance Member Number
.... identifier:medicare S0..1AUMedicareCardNumberMedicare Card Number
.... identifier:dva S0..1AUDVANumberDepartment of Veterans' Affairs (DVA) Number
... 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: Coverage Type and Self-Pay Codes - AU Extended (extensible)
... 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.typeextensibleCoverageTypeAndSelfPayCodesAUExtended
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

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()

Differential View

This structure is derived from AUBaseCoverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*AUBaseCoverageInsurance or medical plan or a payment agreement
au-core-cov-01: The coverage shall at least have a valid identifier or type
... Slices for identifier SC0..*Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumberAn identifier intended for computation
Slice: Unordered, Open by pattern:type
.... identifier:insurancemembernumber S0..1AUInsuranceMemberNumberInsurance Member Number
.... identifier:medicare S0..1AUMedicareCardNumberMedicare Card Number
.... identifier:dva S0..1AUDVANumberDepartment of Veterans' Affairs (DVA) Number
... status S1..1codeactive | cancelled | draft | entered-in-error
... type SC0..1CodeableConceptCoverage category such as medical or accident
Binding: Coverage Type and Self-Pay Codes - AU Extended (extensible)
... 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

Terminology Bindings (Differential)

PathConformanceValueSet
Coverage.typeextensibleCoverageTypeAndSelfPayCodesAUExtended

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..*AUBaseCoverageInsurance 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
... Slices for identifier SC0..*Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumberAn identifier intended for computation
Slice: Unordered, Open by pattern:type
.... identifier:insurancemembernumber S0..1AUInsuranceMemberNumberInsurance Member Number
.... identifier:medicare S0..1AUMedicareCardNumberMedicare Card Number
.... identifier:dva S0..1AUDVANumberDepartment of Veterans' Affairs (DVA) Number
... type SΣC0..1CodeableConceptCoverage category such as medical or accident
Binding: Coverage Type and Self-Pay Codes - AU Extended (extensible)
... 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.typeextensibleCoverageTypeAndSelfPayCodesAUExtended
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..*AUBaseCoverageInsurance 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
... Slices for identifier SC0..*Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumberAn identifier intended for computation
Slice: Unordered, Open by pattern:type
.... identifier:insurancemembernumber S0..1AUInsuranceMemberNumberInsurance Member Number
.... identifier:medicare S0..1AUMedicareCardNumberMedicare Card Number
.... identifier:dva S0..1AUDVANumberDepartment of Veterans' Affairs (DVA) Number
... 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: Coverage Type and Self-Pay Codes - AU Extended (extensible)
... 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.typeextensibleCoverageTypeAndSelfPayCodesAUExtended
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

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()

 

Other representations of profile: CSV, Excel, Schematron

Notes:

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

Any search parameter defined in FHIR may be ‘allowed’ by the system unless explicitly marked as “SHALL NOT”. A few items are marked as MAY in this implementation guide to highlight their potential relevance.

</tr>
Parameter(s) Conformance Type(s) Requirements (when used alone or in combination)
patient SHALL reference The client SHALL provide at least an id value and MAY provide both the Type and id values. The server SHALL support both.
patient+status SHALL reference+token
patient.identifier SHOULD reference.token The client SHALL provide both the system and code values. The server SHALL support both.

The client SHOULD support search using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile. The server SHOULD support search using the using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile.
patient+type SHOULD reference+token
identifier SHOULD token The client SHALL provide at least a code value and MAY provide both the system and code values. The server SHALL support both.
status MAY token The client SHALL provide at least a code value and MAY provide both the system and code values. The server SHALL support both.
type MAY token The client SHALL provide at least a code value and MAY provide both the system and code values. The server SHALL support both.

Mandatory Search Parameters

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

  1. SHALL support searching using the patient search parameter:
    • SHALL support these _revinclude parameters: Provenance:target
    • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])

    GET [base]/Coverage?patient={Type/}[id] or optionally GET [base]/Coverage?patient.identifier=[system|][code]

    Example:

    1. GET [base]/Coverage?patient=5678
    2. GET [base]/Coverage?patient.identifier=http://ns.electronichealth.net.au/id/medicare-number|32788511952
    3. GET [base]/Coverage?patient.identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608833357361

    Implementation Notes: Fetches a bundle of all Coverage resources for the specified patient (how to search by reference and how to search by token)

  2. SHALL support searching using the combination of the patient and status search parameters:
    • SHALL support these _revinclude parameters: Provenance:target

    GET [base]/Coverage?patient={Type/}[id]&status={system|}[code]

    Example:

    1. GET [base]/Coverage?patient=5678&status=active

    Implementation Notes: Fetches a bundle of all Coverage resources for the specified patient and status (how to search by reference and how to search by token)

Optional Search Parameters

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

  1. SHOULD support searching using the identifier search parameter:
    • SHALL support these _revinclude parameters: Provenance:target

    GET [base]/Coverage?identifier={system|}[code]

    Example:

    1. GET [base]/Coverage?identifier=http://aaaaaia.example.com/member/memberid|9999115
    2. GET [base]/Coverage?identifier=http://ns.electronichealth.net.au/id/dva|NBUR9080
    3. GET [base]/Coverage?identifier=233223329&_revinclude=Provenance:target

    Implementation Notes: Fetches a bundle containing any Coverage resources matching the identifier (how to search by token)

  2. SHOULD support searching using the combination of the patient and type search parameters:
    • SHALL support these _revinclude parameters: Provenance:target
    • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])
    • SHOULD support multipleOr search on type (e.g.type={system|}[code],{system|}[code],...)

    GET [base]/Coverage?patient={Type/}[id]&type={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/Coverage?patient=5678&type=pay,PUBLICPOL,VET

    Implementation Notes: Fetches a bundle of all Coverage resources for the specified patient and coverage type code(s). SHOULD support search by multiple codes. The Coverage type parameter searches `Coverage.code only. (how to search by reference and how to search by token)