2026 US Quality Core Implementation Guide
0.5.0 - release United States of America flag

This page is part of the US Quality Core (v0.5.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: US Quality Core Coverage

Official URL: http://fhir.org/guides/onc/us-quality-core/StructureDefinition/us-quality-core-coverage Version: 0.5.0
Active as of 2026-06-05 Computable Name: USQualityCoreCoverage

Profile of Coverage for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

USCDI+ Quality Element Support Expectations

Systems are expected to support this profile as part of implementing USCDI+ Quality V1 in FHIR and meeting the conformance requirements of this guide.

The following elements are specifically relevant to USCDI+ Quality V1 data classes and elements. Systems are expected to support these elements as applicable to their role in US Quality Core data exchange. See the Must Support section of this guide for more information. These elements are tagged as (USCDI+ Quality) in the formal profile views.

USCDI+ Quality Elements:

  • identifier: (USCDI+ Quality) (USCDI) Member ID and other identifiers
  • identifier:memberid: (USCDI+ Quality) (USCDI) Member ID
  • identifier:memberid.type: (USCDI+ Quality) (USCDI) Member Number identifier type
  • status: (USCDI+ Quality) (USCDI) active | cancelled | draft | entered-in-error
  • type: (USCDI+ Quality) (USCDI) Coverage category such as medical or accident
  • subscriberId: (USCDI+ Quality) (USCDI) ID assigned to the subscriber
  • beneficiary: (USCDI+ Quality) (USCDI) Plan beneficiary
  • relationship: (USCDI+ Quality) (USCDI) Beneficiary relationship to the subscriber
  • period: (USCDI+ Quality) (USCDI) Coverage start and end dates
  • payor: (USCDI+ Quality) (USCDI) Issuer of the policy
  • class: (USCDI+ Quality) (USCDI) Additional coverage classifications
  • class:group: (USCDI+ Quality) (USCDI) Group
  • class:group.value: (USCDI+ Quality) (USCDI) Group Identifier
  • class:group.name: (USCDI+ Quality) (USCDI) Human readable description of the type and value
  • class:plan: (USCDI+ Quality) (USCDI) Plan
  • class:plan.value: (USCDI+ Quality) (USCDI) Plan Number
  • class:plan.name: (USCDI+ Quality) (USCDI) Plan Name

Because this profile is derived from US Core, systems are also expected to support Must Support requirements and (USCDI) tagged elements inherited from US Core. The Formal Views section also provides the formal summary, definitions, terminology requirements, and mandatory element requirements.

Profile Specific Implementation Guidance

Additional informational guidance for authoring CQL using this profile is provided in the CQL Authoring Usage (Informational) section of this page.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage C 0..* USCoreCoverageProfile(6.1.0) Insurance or medical plan or a payment agreement
Constraints: us-core-15
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for identifier SΣ 0..* Identifier (USCDI+ Quality) (USCDI) Member ID and other identifiers
Slice: Unordered, Open by pattern:type
.... identifier:memberid SΣC 0..1 Identifier (USCDI+ Quality) (USCDI) Member ID
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type SΣ 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Member Number identifier type
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MB
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
... type SΣ 0..1 CodeableConcept (USCDI+ Quality) (USCDI) Coverage category such as medical or accident
Binding: Payer Type . (extensible): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
... policyHolder Σ 0..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) Owner of the policy
... subscriberId SΣC 0..1 string (USCDI+ Quality) (USCDI) ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(US Quality Core Patient) (USCDI+ Quality) (USCDI) Plan beneficiary
... relationship S 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period SΣ 0..1 Period (USCDI+ Quality) (USCDI) Coverage start and end dates
... payor SΣ 1..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) (USCDI+ Quality) (USCDI) Issuer of the policy
... Slices for class S 0..* BackboneElement (USCDI+ Quality) (USCDI) Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... 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: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
..... value Σ 1..1 string Value associated with the type
.... class:group S 0..1 BackboneElement (USCDI+ Quality) (USCDI) Group
..... 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: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: group
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) (USCDI) Group Identifier
..... name SΣ 0..1 string (USCDI+ Quality) (USCDI) Human readable description of the type and value
.... class:plan S 0..1 BackboneElement (USCDI+ Quality) (USCDI) Plan
..... 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: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: plan
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) (USCDI) Plan Number
..... name SΣ 0..1 string (USCDI+ Quality) (USCDI) Plan Name

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Coverage.identifier:memberid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Coverage.identifier:memberid.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Coverage.type Base extensible Payer Type . 📦20221118 VSAC v0.18
Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
Coverage.class.type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:group.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:plan.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Coverage 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 error Coverage 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 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-15 error Coverage Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* USCoreCoverageProfile(6.1.0) Insurance or medical plan or a payment agreement
... Slices for identifier 0..* Identifier (USCDI+ Quality) (USCDI) Member ID and other identifiers
Slice: Unordered, Open by pattern:type
.... identifier:memberid 0..1 Identifier (USCDI+ Quality) (USCDI) Member ID
..... type 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Member Number identifier type
... status 1..1 code (USCDI+ Quality) (USCDI) active | cancelled | draft | entered-in-error
... type 0..1 CodeableConcept (USCDI+ Quality) (USCDI) Coverage category such as medical or accident
Binding: Payer Type . (extensible): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
... subscriberId 0..1 string (USCDI+ Quality) (USCDI) ID assigned to the subscriber
... beneficiary 1..1 Reference(US Quality Core Patient) (USCDI+ Quality) (USCDI) Plan beneficiary
... relationship 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Beneficiary relationship to the subscriber
... period 0..1 Period (USCDI+ Quality) (USCDI) Coverage start and end dates
... payor 1..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) (USCDI+ Quality) (USCDI) Issuer of the policy
... Slices for class 0..* BackboneElement (USCDI+ Quality) (USCDI) Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:group 0..1 BackboneElement (USCDI+ Quality) (USCDI) Group
..... value 1..1 string (USCDI+ Quality) (USCDI) Group Identifier
..... name 0..1 string (USCDI+ Quality) (USCDI) Human readable description of the type and value
.... class:plan 0..1 BackboneElement (USCDI+ Quality) (USCDI) Plan
..... value 1..1 string (USCDI+ Quality) (USCDI) Plan Number
..... name 0..1 string (USCDI+ Quality) (USCDI) Plan Name

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Coverage.type Base extensible Payer Type . 📦20221118 VSAC v0.18
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage C 0..* USCoreCoverageProfile(6.1.0) Insurance or medical plan or a payment agreement
Constraints: us-core-15
... 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for identifier SΣ 0..* Identifier (USCDI+ Quality) (USCDI) Member ID and other identifiers
Slice: Unordered, Open by pattern:type
.... identifier:memberid SΣC 0..1 Identifier (USCDI+ Quality) (USCDI) Member ID
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type SΣ 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Member Number identifier type
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MB
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 0..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code (USCDI+ Quality) (USCDI) active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type SΣ 0..1 CodeableConcept (USCDI+ Quality) (USCDI) Coverage category such as medical or accident
Binding: Payer Type . (extensible): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
... policyHolder Σ 0..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) Owner of the policy
... subscriber Σ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
... subscriberId SΣC 0..1 string (USCDI+ Quality) (USCDI) ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(US Quality Core Patient) (USCDI+ Quality) (USCDI) Plan beneficiary
... dependent Σ 0..1 string Dependent number
... relationship S 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period SΣ 0..1 Period (USCDI+ Quality) (USCDI) Coverage start and end dates
... payor SΣ 1..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) (USCDI+ Quality) (USCDI) Issuer of the policy
... Slices for class S 0..* BackboneElement (USCDI+ Quality) (USCDI) Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... 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: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
..... value Σ 1..1 string Value associated with the type
..... name Σ 0..1 string Human readable description of the type and value
.... class:group S 0..1 BackboneElement (USCDI+ Quality) (USCDI) Group
..... 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: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: group
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) (USCDI) Group Identifier
..... name SΣ 0..1 string (USCDI+ Quality) (USCDI) Human readable description of the type and value
.... class:plan S 0..1 BackboneElement (USCDI+ Quality) (USCDI) Plan
..... 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: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: plan
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) (USCDI) Plan Number
..... name SΣ 0..1 string (USCDI+ Quality) (USCDI) Plan Name
... 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

Path Status Usage ValueSet Version Source
Coverage.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Coverage.identifier:memberid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Coverage.identifier:memberid.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Coverage.type Base extensible Payer Type . 📦20221118 VSAC v0.18
Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
Coverage.class.type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:group.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:plan.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.costToBeneficiary.​type Base extensible Coverage Copay Type Codes 📦4.0.1 FHIR Std.
Coverage.costToBeneficiary.​exception.type Base example Example Coverage Financial Exception Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Coverage 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 error Coverage 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 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-15 error Coverage Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

Summary

Mandatory: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Coverage.identifier
  • The element 1 is sliced based on the value of Coverage.class

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage C 0..* USCoreCoverageProfile(6.1.0) Insurance or medical plan or a payment agreement
Constraints: us-core-15
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for identifier SΣ 0..* Identifier (USCDI+ Quality) (USCDI) Member ID and other identifiers
Slice: Unordered, Open by pattern:type
.... identifier:memberid SΣC 0..1 Identifier (USCDI+ Quality) (USCDI) Member ID
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type SΣ 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Member Number identifier type
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MB
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
... type SΣ 0..1 CodeableConcept (USCDI+ Quality) (USCDI) Coverage category such as medical or accident
Binding: Payer Type . (extensible): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
... policyHolder Σ 0..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) Owner of the policy
... subscriberId SΣC 0..1 string (USCDI+ Quality) (USCDI) ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(US Quality Core Patient) (USCDI+ Quality) (USCDI) Plan beneficiary
... relationship S 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period SΣ 0..1 Period (USCDI+ Quality) (USCDI) Coverage start and end dates
... payor SΣ 1..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) (USCDI+ Quality) (USCDI) Issuer of the policy
... Slices for class S 0..* BackboneElement (USCDI+ Quality) (USCDI) Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... 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: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
..... value Σ 1..1 string Value associated with the type
.... class:group S 0..1 BackboneElement (USCDI+ Quality) (USCDI) Group
..... 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: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: group
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) (USCDI) Group Identifier
..... name SΣ 0..1 string (USCDI+ Quality) (USCDI) Human readable description of the type and value
.... class:plan S 0..1 BackboneElement (USCDI+ Quality) (USCDI) Plan
..... 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: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: plan
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) (USCDI) Plan Number
..... name SΣ 0..1 string (USCDI+ Quality) (USCDI) Plan Name

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Coverage.identifier:memberid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Coverage.identifier:memberid.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Coverage.type Base extensible Payer Type . 📦20221118 VSAC v0.18
Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
Coverage.class.type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:group.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:plan.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Coverage 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 error Coverage 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 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-15 error Coverage Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

Differential View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* USCoreCoverageProfile(6.1.0) Insurance or medical plan or a payment agreement
... Slices for identifier 0..* Identifier (USCDI+ Quality) (USCDI) Member ID and other identifiers
Slice: Unordered, Open by pattern:type
.... identifier:memberid 0..1 Identifier (USCDI+ Quality) (USCDI) Member ID
..... type 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Member Number identifier type
... status 1..1 code (USCDI+ Quality) (USCDI) active | cancelled | draft | entered-in-error
... type 0..1 CodeableConcept (USCDI+ Quality) (USCDI) Coverage category such as medical or accident
Binding: Payer Type . (extensible): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
... subscriberId 0..1 string (USCDI+ Quality) (USCDI) ID assigned to the subscriber
... beneficiary 1..1 Reference(US Quality Core Patient) (USCDI+ Quality) (USCDI) Plan beneficiary
... relationship 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Beneficiary relationship to the subscriber
... period 0..1 Period (USCDI+ Quality) (USCDI) Coverage start and end dates
... payor 1..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) (USCDI+ Quality) (USCDI) Issuer of the policy
... Slices for class 0..* BackboneElement (USCDI+ Quality) (USCDI) Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:group 0..1 BackboneElement (USCDI+ Quality) (USCDI) Group
..... value 1..1 string (USCDI+ Quality) (USCDI) Group Identifier
..... name 0..1 string (USCDI+ Quality) (USCDI) Human readable description of the type and value
.... class:plan 0..1 BackboneElement (USCDI+ Quality) (USCDI) Plan
..... value 1..1 string (USCDI+ Quality) (USCDI) Plan Number
..... name 0..1 string (USCDI+ Quality) (USCDI) Plan Name

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Coverage.type Base extensible Payer Type . 📦20221118 VSAC v0.18

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage C 0..* USCoreCoverageProfile(6.1.0) Insurance or medical plan or a payment agreement
Constraints: us-core-15
... 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for identifier SΣ 0..* Identifier (USCDI+ Quality) (USCDI) Member ID and other identifiers
Slice: Unordered, Open by pattern:type
.... identifier:memberid SΣC 0..1 Identifier (USCDI+ Quality) (USCDI) Member ID
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type SΣ 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Member Number identifier type
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MB
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 0..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code (USCDI+ Quality) (USCDI) active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type SΣ 0..1 CodeableConcept (USCDI+ Quality) (USCDI) Coverage category such as medical or accident
Binding: Payer Type . (extensible): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
... policyHolder Σ 0..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) Owner of the policy
... subscriber Σ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
... subscriberId SΣC 0..1 string (USCDI+ Quality) (USCDI) ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(US Quality Core Patient) (USCDI+ Quality) (USCDI) Plan beneficiary
... dependent Σ 0..1 string Dependent number
... relationship S 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period SΣ 0..1 Period (USCDI+ Quality) (USCDI) Coverage start and end dates
... payor SΣ 1..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) (USCDI+ Quality) (USCDI) Issuer of the policy
... Slices for class S 0..* BackboneElement (USCDI+ Quality) (USCDI) Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... 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: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
..... value Σ 1..1 string Value associated with the type
..... name Σ 0..1 string Human readable description of the type and value
.... class:group S 0..1 BackboneElement (USCDI+ Quality) (USCDI) Group
..... 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: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: group
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) (USCDI) Group Identifier
..... name SΣ 0..1 string (USCDI+ Quality) (USCDI) Human readable description of the type and value
.... class:plan S 0..1 BackboneElement (USCDI+ Quality) (USCDI) Plan
..... 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: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: plan
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) (USCDI) Plan Number
..... name SΣ 0..1 string (USCDI+ Quality) (USCDI) Plan Name
... 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

Path Status Usage ValueSet Version Source
Coverage.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Coverage.identifier:memberid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Coverage.identifier:memberid.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Coverage.type Base extensible Payer Type . 📦20221118 VSAC v0.18
Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
Coverage.class.type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:group.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:plan.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.costToBeneficiary.​type Base extensible Coverage Copay Type Codes 📦4.0.1 FHIR Std.
Coverage.costToBeneficiary.​exception.type Base example Example Coverage Financial Exception Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Coverage 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 error Coverage 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 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-15 error Coverage Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

Summary

Mandatory: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Coverage.identifier
  • The element 1 is sliced based on the value of Coverage.class

 

Other representations of profile: CSV, Excel, Schematron

Notes:

CQL Authoring Usage (Informational)

define "SDE Payer":
  [Coverage: type in "Payer"] Payer
    return {
      code: Payer.type,
      period: Payer.period
    }