This page is part of the Interoperability of Clic Santé (v1.0.0: 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

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Resource Profile: Coverage ( Experimental )

This is an coverage that aligns with Clic Sante's systems.

Usage:

• Examples for this Resource Profile: Coverage/ExampleActiveCoverage

Formal Views of Profile Content

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

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
coverageNam		0..1	string	The nam of the patient URL: http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
coverageNamSequentialNumber		0..1	string	The nam sequential number of the patient URL: http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam-sequential-number ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children
beneficiary	Σ	1..1	Reference(Patient)	Plan beneficiary ele-1: All FHIR elements must have a @value or children
payor	Σ	1..*	Reference(Organization | Patient | RelatedPerson)	Issuer of the policy ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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()

This structure is derived from Coverage

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement
implicitRules		0..0
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
coverageNam		0..1	string	The nam of the patient URL: http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam
coverageNamSequentialNumber		0..1	string	The nam sequential number of the patient URL: http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam-sequential-number
modifierExtension		0..0
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
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
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
coverageNam		0..1	string	The nam of the patient URL: http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam
coverageNamSequentialNumber		0..1	string	The nam sequential number of the patient URL: http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam-sequential-number
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: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.
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: 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
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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Coverage.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Coverage.type	preferred	CoverageTypeAndSelf-PayCodes http://hl7.org/fhir/ValueSet/coverage-type from the FHIR Standard
Coverage.relationship	extensible	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes http://hl7.org/fhir/ValueSet/coverage-copay-type from the FHIR Standard
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes http://hl7.org/fhir/ValueSet/coverage-financial-exception from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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()

This structure is derived from Coverage

Summary

Prohibited: 2 elements

Extensions

This structure refers to these extensions:

• http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam
• http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam-sequential-number

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
coverageNam		0..1	string	The nam of the patient URL: http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
coverageNamSequentialNumber		0..1	string	The nam sequential number of the patient URL: http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam-sequential-number ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children
beneficiary	Σ	1..1	Reference(Patient)	Plan beneficiary ele-1: All FHIR elements must have a @value or children
payor	Σ	1..*	Reference(Organization | Patient | RelatedPerson)	Issuer of the policy ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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()

Differential View

This structure is derived from Coverage

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement
implicitRules		0..0
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
coverageNam		0..1	string	The nam of the patient URL: http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam
coverageNamSequentialNumber		0..1	string	The nam sequential number of the patient URL: http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam-sequential-number
modifierExtension		0..0
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
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
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
coverageNam		0..1	string	The nam of the patient URL: http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam
coverageNamSequentialNumber		0..1	string	The nam sequential number of the patient URL: http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam-sequential-number
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: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.
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: 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
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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Coverage.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Coverage.type	preferred	CoverageTypeAndSelf-PayCodes http://hl7.org/fhir/ValueSet/coverage-type from the FHIR Standard
Coverage.relationship	extensible	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes http://hl7.org/fhir/ValueSet/coverage-copay-type from the FHIR Standard
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes http://hl7.org/fhir/ValueSet/coverage-financial-exception from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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()

This structure is derived from Coverage

Summary

Prohibited: 2 elements

Extensions

This structure refers to these extensions:

• http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam
• http://documentation.clicsante.ca/fhir/base/StructureDefinition/coverage-nam-sequential-number

Other representations of profile: CSV, Excel, Schematron