HL7® FHIR® New Zealand Base Implementation Guide
3.0.1

HL7® FHIR® New Zealand Base Implementation Guide, published by HL7 New Zealand

Resource Profile: Coverage resource for use in NZ (Trial use)

Official URL: http://hl7.org.nz/fhir/StructureDefinition/NzCoverage Version: 1.0.0
Draft as of 2024-08-14 Computable Name: NzCoverage

Coverage resource for use in NZ (Trial use)

Trial use profile on Coverage for NZ use. Primarily changing the type valueset. Inclusion of the profile in future IG versions will depend on Implementer feedback.

Usage:

Formal Views of Profile Content

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

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..* Coverage Insurance or medical plan or a payment agreement
... type 0..1 CodeableConcept Coverage category such as medical or accident
Binding: Coverage Type (extensible)
... class
.... type 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: Coverage Category (extensible)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Coverage.typeextensibleCoverageType (a valid code from Coverage type)
https://nzhts.digital.health.nz/fhir/ValueSet/coverage-type-code
from this IG
Coverage.class.typeextensibleCoverageCategory (a valid code from Coverage category)
https://nzhts.digital.health.nz/fhir/ValueSet/coverage-category-code
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..* Coverage Insurance or medical plan or a payment agreement
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... beneficiary Σ 1..1 Reference(Patient) Plan beneficiary
... payor Σ 1..* Reference(Organization | Patient | RelatedPerson) Issuer of the policy

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.typeextensibleCoverageType (a valid code from Coverage type)
https://nzhts.digital.health.nz/fhir/ValueSet/coverage-type-code
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..* Coverage Insurance or medical plan or a payment agreement
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for the coverage
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ 0..1 CodeableConcept Coverage category such as medical or accident
Binding: Coverage Type (extensible)
... policyHolder Σ 0..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
... subscriber Σ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
... subscriberId Σ 0..1 string ID assigned to the subscriber
... beneficiary Σ 1..1 Reference(Patient) Plan beneficiary
... dependent Σ 0..1 string Dependent number
... relationship 0..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period Σ 0..1 Period Coverage start and end dates
... payor Σ 1..* Reference(Organization | Patient | RelatedPerson) Issuer of the policy
... class 0..* BackboneElement Additional coverage classifications
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: Coverage Category (extensible)
.... value Σ 1..1 string Value associated with the type
.... name Σ 0..1 string Human readable description of the type and value
... order Σ 0..1 positiveInt Relative order of the coverage
... network Σ 0..1 string Insurer network
... costToBeneficiary 0..* BackboneElement Patient payments for services/products
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type Σ 0..1 CodeableConcept Cost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ 1..1 The amount or percentage due from the beneficiary
..... valueQuantity Quantity(SimpleQuantity)
..... valueMoney Money
.... exception 0..* BackboneElement Exceptions for patient payments
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Exception category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ 0..1 Period The effective period of the exception
... subrogation 0..1 boolean Reimbursement to insurer
... contract 0..* Reference(Contract) Contract details

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.typeextensibleCoverageType (a valid code from Coverage type)
https://nzhts.digital.health.nz/fhir/ValueSet/coverage-type-code
from this IG
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.class.typeextensibleCoverageCategory (a valid code from Coverage category)
https://nzhts.digital.health.nz/fhir/ValueSet/coverage-category-code
from this IG
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
http://hl7.org/fhir/ValueSet/coverage-copay-type
from the FHIR Standard
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
http://hl7.org/fhir/ValueSet/coverage-financial-exception
from the FHIR Standard

This structure is derived from Coverage

Summary

Differential View

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..* Coverage Insurance or medical plan or a payment agreement
... type 0..1 CodeableConcept Coverage category such as medical or accident
Binding: Coverage Type (extensible)
... class
.... type 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: Coverage Category (extensible)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Coverage.typeextensibleCoverageType (a valid code from Coverage type)
https://nzhts.digital.health.nz/fhir/ValueSet/coverage-type-code
from this IG
Coverage.class.typeextensibleCoverageCategory (a valid code from Coverage category)
https://nzhts.digital.health.nz/fhir/ValueSet/coverage-category-code
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..* Coverage Insurance or medical plan or a payment agreement
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... beneficiary Σ 1..1 Reference(Patient) Plan beneficiary
... payor Σ 1..* Reference(Organization | Patient | RelatedPerson) Issuer of the policy

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.typeextensibleCoverageType (a valid code from Coverage type)
https://nzhts.digital.health.nz/fhir/ValueSet/coverage-type-code
from this IG

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..* Coverage Insurance or medical plan or a payment agreement
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for the coverage
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ 0..1 CodeableConcept Coverage category such as medical or accident
Binding: Coverage Type (extensible)
... policyHolder Σ 0..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
... subscriber Σ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
... subscriberId Σ 0..1 string ID assigned to the subscriber
... beneficiary Σ 1..1 Reference(Patient) Plan beneficiary
... dependent Σ 0..1 string Dependent number
... relationship 0..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period Σ 0..1 Period Coverage start and end dates
... payor Σ 1..* Reference(Organization | Patient | RelatedPerson) Issuer of the policy
... class 0..* BackboneElement Additional coverage classifications
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: Coverage Category (extensible)
.... value Σ 1..1 string Value associated with the type
.... name Σ 0..1 string Human readable description of the type and value
... order Σ 0..1 positiveInt Relative order of the coverage
... network Σ 0..1 string Insurer network
... costToBeneficiary 0..* BackboneElement Patient payments for services/products
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type Σ 0..1 CodeableConcept Cost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ 1..1 The amount or percentage due from the beneficiary
..... valueQuantity Quantity(SimpleQuantity)
..... valueMoney Money
.... exception 0..* BackboneElement Exceptions for patient payments
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Exception category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ 0..1 Period The effective period of the exception
... subrogation 0..1 boolean Reimbursement to insurer
... contract 0..* Reference(Contract) Contract details

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.typeextensibleCoverageType (a valid code from Coverage type)
https://nzhts.digital.health.nz/fhir/ValueSet/coverage-type-code
from this IG
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.class.typeextensibleCoverageCategory (a valid code from Coverage category)
https://nzhts.digital.health.nz/fhir/ValueSet/coverage-category-code
from this IG
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
http://hl7.org/fhir/ValueSet/coverage-copay-type
from the FHIR Standard
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
http://hl7.org/fhir/ValueSet/coverage-financial-exception
from the FHIR Standard

This structure is derived from Coverage

Summary

 

Other representations of profile: CSV, Excel, Schematron