PrescribeIT® Specification and Guide Version 5.0


v5.0 of this specification has been superseded by v5.3. v5.3 is compatible but adds additional features for Quebec.

The version (Bundle.meta.tag:version) that is sent in the message will remain PrescribeIT5.0

 

Definitions for the profile-coverage Profile.

1. Coverage
Definition

Financial instrument which may be used to pay for or reimburse health care products and services.

Control0..*
Must Supporttrue
Max Length0
2. Coverage.id
Definition

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

Control1..1
Typeid
Must Supporttrue
Comments

Usage Note: This will usually be a GUID and is assigned by the sending application. Ideally it should be consistent for all messages referencing this same set of coverage information.

Max Length0
3. Coverage.meta
Definition

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

Control0..1
TypeMeta
Max Length0
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.

Control0..1
Typeuri
Is Modifiertrue
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 as much as possible.

Max Length0
5. Coverage.language
Definition

The base language in which the resource is written.

Control0..1
BindingThe codes SHALL be taken from http://tools.ietf.org/html/bcp47 A human language.

Typecode
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).

Max Length0
6. Coverage.text
Definition

A human-readable narrative that contains a summary of the resource, and may 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 This element is affected by the following invariants: dom-1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.

Max Length0
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
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.

Max Length0
8. Coverage.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. In order 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.

Control0..*
TypeExtension
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.

Max Length0
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. Usually modifier elements provide negation or qualification. In order 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.

Control0..*
TypeExtension
Is Modifiertrue
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.

Max Length0
10. Coverage.issuer[x]
Definition

The program or plan underwriter or payor.

Control1..1
TypeReference
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

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

Max Length0
SlicingThis element introduces a set of slices on Coverage.issuer[x]. The slices are unordered and Closed, and can be differentiated using the following discriminators:
  • type @ $this
11. Coverage.issuer[x]:issuerReference
SliceNameissuerReference
Definition

The program or plan underwriter or payor.

Control1..1
TypeReference(Organization)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Requirements

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

Comments

This is currently required in the spec. I've submitted a request to loosen it.

Max Length0
12. Coverage.issuer[x]:issuerReference.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Max Length0
13. Coverage.issuer[x]:issuerReference.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Control0..*
TypeExtension
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.

Max Length0
14. Coverage.issuer[x]:issuerReference.reference
Definition

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Control0..1 This element is affected by the following invariants: ref-1
Typestring
Comments

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Max Length0
15. Coverage.issuer[x]:issuerReference.display
Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Control1..1
Typestring
Must Supporttrue
Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Max Length500
16. Coverage.bin
Definition

Business Identification Number (BIN number) used to identify the routing of eClaims.

Control0..1
Typestring
Max Length0
17. 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
Max Length0
18. Coverage.type
Definition

The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health.

Control0..1
BindingFor example codes, see ActCoverageTypeCode The type of insurance: public health, worker compensation; private accident, auto, private health, etc.).

TypeCoding
Must Supporttrue
Requirements

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

Max Length0
19. Coverage.type.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Max Length0
20. Coverage.type.extension
Definition

An Extension

Control0..*
TypeExtension
Must Supporttrue
Max Length0
SlicingThis element introduces a set of slices on Coverage.type.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
21. Coverage.type.extension:description
SliceNamedescription
Definition

Allows the specification of a free-text description for a coded element that has a type of Coding rather than CodeableConcept.

Control0..1
TypeExtension(Coding Text) (Extension Type: string)
Must Supporttrue
Max Length0
22. Coverage.type.extension:description.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
23. Coverage.type.extension:description.extension
Definition

An Extension

Control0..0
TypeExtension
24. Coverage.type.extension:description.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Control1..1
Typeuri
Must Supporttrue
Comments

Fixed value: http://sharedhealth.exchange/fhir/StructureDefinition/ext-coding-text

Fixed Valuehttp://sharedhealth.exchange/fhir/StructureDefinition/ext-coding-text
25. Coverage.type.extension:description.value[x]
Definition

Allows the specification of a free-text description for a coded element that has a type of Coding rather than CodeableConcept.

Control1..1
Typestring
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Max Length5000
26. Coverage.type.system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Control0..1
Typeuri
Must Supporttrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

Max Length0
27. Coverage.type.version
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

NoteThis is a business versionId, not a resource version id (see discussion)
Control0..1
Typestring
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

Max Length0
28. Coverage.type.code
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Control0..1
Typecode
Must Supporttrue
Requirements

Need to refer to a particular code in the system.

Max Length0
29. Coverage.type.display
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Control0..1
Typestring
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Max Length0
30. Coverage.type.userSelected
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Control0..1
Typeboolean
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

Max Length0
31. Coverage.planholder[x]
Definition

The party who 'owns' the insurance contractual relationship to the policy or to whom the benefit of the policy is due.

Control1..1
TypeIdentifier
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifiertrue
Max Length0
SlicingThis element introduces a set of slices on Coverage.planholder[x]. The slices are unordered and Closed, and can be differentiated using the following discriminators:
  • type @ $this
32. Coverage.planholder[x]:planholderIdentifier
SliceNameplanholderIdentifier
Definition

The party who 'owns' the insurance contractual relationship to the policy or to whom the benefit of the policy is due.

Control1..1
TypeIdentifier
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifiertrue
Must Supporttrue
Max Length0
33. Coverage.planholder[x]:planholderIdentifier.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Max Length0
34. Coverage.planholder[x]:planholderIdentifier.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Control0..*
TypeExtension
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.

Max Length0
35. Coverage.planholder[x]:planholderIdentifier.use
Definition

The purpose of this identifier.

Control0..1
BindingThe codes SHALL be taken from IdentifierUse Identifies the purpose for this identifier, if known .

Typecode
Is Modifiertrue
Requirements

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Comments

This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Max Length0
36. Coverage.planholder[x]:planholderIdentifier.type
Definition

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

Control0..1
BindingThe codes SHALL be taken from Identifier Type Codes; other codes may be used where these codes are not suitable A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

TypeCodeableConcept
Requirements

Allows users to make use of identifiers when the identifier system is not known.

Comments

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

Max Length0
37. Coverage.planholder[x]:planholderIdentifier.system
Definition

Establishes the namespace in which set of possible id values is unique.

Control0..1
Typeuri
Requirements

There are many sequences of identifiers. To perform matching, we need to know what sequence we're dealing with. The system identifies a particular sequence or set of unique identifiers.

Max Length0
Example
General:http://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the Identifier.value itself is a full uri
38. Coverage.planholder[x]:planholderIdentifier.value
Definition

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

Control1..1
Typestring
Must Supporttrue
Comments

Conformance Rule: This element is required because of rules in the FHIR specification which may be relaxed in a future specification. If no useful value is known, this element may be populated 'Unknown'.

Max Length500
Example
General:123456
39. Coverage.planholder[x]:planholderIdentifier.period
Definition

Time period during which identifier is/was valid for use.

Control0..1
TypePeriod
Max Length0
40. Coverage.planholder[x]:planholderIdentifier.assigner
Definition

Organization that issued/manages the identifier.

Control0..1
TypeReference(Organization)
Comments

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

Max Length0
41. Coverage.beneficiary[x]
Definition

The party who benefits from the insurance coverage.

Control1..1
TypeReference
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifiertrue
Max Length0
SlicingThis element introduces a set of slices on Coverage.beneficiary[x]. The slices are unordered and Closed, and can be differentiated using the following discriminators:
  • type @ $this
42. Coverage.beneficiary[x]:beneficiaryReference
SliceNamebeneficiaryReference
Definition

A reference from one resource to another.

Control1..1
TypeReference(Shared Health Reference)(Shared Health Patient)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifiertrue
Must Supporttrue
Max Length0
43. Coverage.relationship
Definition

The relationship of the patient to the planholdersubscriber).

Control1..1
BindingFor example codes, see Beneficiary Relationship Codes The code for the relationship of the patient to the subscriber.

TypeCoding
Must Supporttrue
Requirements

To determine relationship between the patient and the subscriber.

Max Length0
44. Coverage.relationship.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Max Length0
45. Coverage.relationship.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Control0..*
TypeExtension
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.

Max Length0
46. Coverage.relationship.system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Control0..1
Typeuri
Must Supporttrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

Fixed value: http://hl7.org/fhir/v3/NullFlavor

Max Length0
Fixed Valuehttp://hl7.org/fhir/v3/NullFlavor
47. Coverage.relationship.version
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

NoteThis is a business versionId, not a resource version id (see discussion)
Control0..1
Typestring
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

Max Length0
48. Coverage.relationship.code
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Control0..1
Typecode
Must Supporttrue
Requirements

Need to refer to a particular code in the system.

Comments

Fixed value: UNK

Max Length0
Fixed ValueUNK
49. Coverage.relationship.display
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Control0..1
Typestring
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Max Length0
50. Coverage.relationship.userSelected
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Control0..1
Typeboolean
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

Max Length0
51. Coverage.identifier
Definition

The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Subscriber Id, Certificate number or Personal Health Number or Case ID.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
Must Supporttrue
Requirements

This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below.

Max Length0
52. Coverage.identifier.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Max Length0
53. Coverage.identifier.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Control0..*
TypeExtension
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.

Max Length0
54. Coverage.identifier.use
Definition

The purpose of this identifier.

Control0..1
BindingThe codes SHALL be taken from IdentifierUse Identifies the purpose for this identifier, if known .

Typecode
Is Modifiertrue
Requirements

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Comments

This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Max Length0
55. Coverage.identifier.type
Definition

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

Control0..1
BindingThe codes SHALL be taken from Identifier Type Codes; other codes may be used where these codes are not suitable A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

TypeCodeableConcept
Requirements

Allows users to make use of identifiers when the identifier system is not known.

Comments

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

Max Length0
56. Coverage.identifier.system
Definition

Establishes the namespace in which set of possible id values is unique.

Control0..1
Typeuri
Requirements

There are many sequences of identifiers. To perform matching, we need to know what sequence we're dealing with. The system identifies a particular sequence or set of unique identifiers.

Max Length0
Example
General:http://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the Identifier.value itself is a full uri
57. Coverage.identifier.value
Definition

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

Control1..1
Typestring
Must Supporttrue
Comments

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension.

Max Length0
Example
General:123456
???:123456
58. Coverage.identifier.period
Definition

Time period during which identifier is/was valid for use.

Control0..1
TypePeriod
Max Length0
59. Coverage.identifier.assigner
Definition

Organization that issued/manages the identifier.

Control0..1
TypeReference(Organization)
Comments

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

Max Length0
60. Coverage.group
Definition

Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer group. May also be referred to as a Policy or Group ID.

Control0..1
Typestring
Must Supporttrue
Max Length0
61. Coverage.plan
Definition

Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer group. May also be referred to as a Policy or Group ID.

Control0..1
Typestring
Max Length0
62. Coverage.subPlan
Definition

Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a specific employer group within a class of employers. May be referred to as a Section or Division ID.

Control0..1
Typestring
Max Length0
63. Coverage.dependent
Definition

A unique identifier for a dependent under the coverage.

Control0..1
TypepositiveInt
Requirements

For some coverage a single identifier is issued to the PolicyHolder and a dependent number issued to each beneficiary.

Max Length0
64. Coverage.sequence
Definition

An optional counter for a particular instance of the identified coverage which increments upon each renewal.

Control0..1
TypepositiveInt
Requirements

Some coverage, for example social plans, may be offered in short time increments, for example for a week or a month at a time, so while the rest of the plan details and identifiers may remain constant over time, the instance is incremented with each renewal and provided to the covered party on their 'card'.

Max Length0
65. Coverage.exception
Definition

Factors which may influence the applicability of coverage.

Control0..*
BindingFor example codes, see Exception Codes The eligibility exception codes.

TypeCoding
Requirements

To determine extenuating circumstances for coverage.

Max Length0
66. Coverage.school
Definition

Name of school for over-aged dependants.

Control0..1
Typestring
Requirements

Often required for over-age dependents.

Max Length0
67. Coverage.network
Definition

The identifier for a community of providers.

Control0..1
Typestring
Max Length0
68. Coverage.contract
Definition

The policy(s) which constitute this insurance coverage.

Control0..*
TypeReference(Contract)
Max Length0