Generated Narrative: StructureDefinition mn-core-coverage Name Flags Card. Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> Coverage 0..* Coverage Insurance or medical plan or a payment agreement #xD; status S 1..1 code Статус (active | cancelled | draft | entered-in-error) #xD; type S 0..1 CodeableConcept Даатгалын төрөл — НЭМ, ХХД, тусгай даатгал Binding: CoverageTypeAndSelf-PayCodes (extensible) #xD; subscriberId S 0..1 string Даатгалын дэвтрийн дугаар / НЭМ ID #xD; beneficiary S 1..1 Reference(Монгол улсын үндсэн Patient профайл) Даатгуулагч өвчтөн #xD; period S 0..1 Period Даатгалын хүчинтэй хугацаа #xD; start S 0..1 dateTime Starting time with inclusive boundary #xD; end S 0..1 dateTime End time with inclusive boundary, if not ongoing #xD; payor S 1..* Reference(Монгол улсын үндсэн Organization профайл) Даатгагч байгууллага (НЭМД, Эрүүл мэндийн даатгалын газар) #xD; class S 0..* BackboneElement Даатгалын бүлэглэл (ажилтан, тэтгэвэрт, хүүхэд гэх мэт) #xD; type S 1..1 CodeableConcept Type of class such as 'group' or 'plan' #xD; value S 1..1 string Value associated with the type #xD; name S 0..1 string Human readable description of the type and value #xD; order S 0..1 positiveInt Үндсэн / нэмэлт даатгалын дараалал (1=үндсэн) #xD; network S 0..1 string Үйлчилгээний сүлжээ #xD; costToBeneficiary S 0..* BackboneElement Өвчтөний хариуцах хэсэг (хамтран даах) #xD; <img src="[binary]" alt="doco" style="background-color: inherit"/> Documentation for this format
Монгол улсын үндсэн Coverage профайл (НЭМ)
Эрүүл мэндийн хөгжлийн төв (Health Development Center, Mongolia)
Эрүүл мэндийн хөгжлийн төв (Health Development Center)
Нийгмийн эрүүл мэндийн даатгал (НЭМ/НЭМД)-ын мэдэгдэл. Encounter.insurance-д лавлагдана.
Canadian Dental Association eclaims standard
Canadian Pharmacy Associaiton eclaims standard
Insurance or medical plan or a payment agreement
Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.
The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
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()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
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()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
A set of rules under which this content was created
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The base language in which the resource is written.
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).
Text summary of the resource, for human interpretation
A human-readable narrative that contains a summary of the resource and can 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.
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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.
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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Additional content defined by implementations
May be used to represent additional information that is not part of the basic definition of the resource. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
A unique identifier assigned to this coverage.
The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.
Allows coverages to be distinguished and referenced.
Статус (active | cancelled | draft | entered-in-error)
This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.
Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.
This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
A code specifying the state of the resource instance.
Даатгалын төрөл — НЭМ, ХХД, тусгай даатгал
The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.
The order of application of coverages is dependent on the types of coverage.
The party who 'owns' the insurance policy.
For example: may be an individual, corporation or the subscriber's employer.
This provides employer information in the case of Worker's Compensation and other policies.
IN1-16, 18, 19-name of insured, address, date of birth
The party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due.
May be self or a parent in the case of dependants.
This is the party who is entitled to the benfits under the policy.
The insurer assigned ID for the Subscriber.
The insurer requires this identifier on correspondance and claims (digital and otherwise).
The party who benefits from the insurance coverage; the patient when products and/or services are provided.
This is the party who receives treatment for which the costs are reimbursed under the coverage.
A unique identifier for a dependent under the coverage.
Periodically the member number is constructed from the subscriberId and the dependant number.
For some coverages a single identifier is issued to the Subscriber and then a unique dependent number is issued to each beneficiary.
- No exact HL7 v2 equivalent concept seems to exist;
Beneficiary relationship to the subscriber
The relationship of beneficiary (patient) to the subscriber.
Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.
To determine relationship between the patient and the subscriber to determine coordination of benefits.
The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
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.
Some insurers require the submission of the coverage term.
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
The start of the period. The boundary is inclusive.
If the low element is missing, the meaning is that the low boundary is not known.
End time with inclusive boundary, if not ongoing
The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.
The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.
If the end of the period is missing, it means that the period is ongoing
Даатгагч байгууллага (НЭМД, Эрүүл мэндийн даатгалын газар)
The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.
May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations.
Need to identify the issuer to target for claim processing and for coordination of benefit processing.
Даатгалын бүлэглэл (ажилтан, тэтгэвэрт, хүүхэд гэх мэт)
A suite of underwriter specific classifiers.
For example may be used to identify a class of coverage or employer group, Policy, Plan.
The codes provided on the health card which identify or confirm the specific policy for the insurer.
Extensions that cannot be ignored even if unrecognized
May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
The type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan.
The insurer issued label for a specific health card value.
The policy classifications, eg. Group, Plan, Class, etc.
The alphanumeric string value associated with the insurer issued label.
The insurer issued label and value are necessary to identify the specific policy.
Human readable description of the type and value
Used to provide a meaningful description in correspondence to the patient.
Үндсэн / нэмэлт даатгалын дараалал (1=үндсэн)
The order of applicability of this coverage relative to other coverages which are currently in force. Note, there may be gaps in the numbering and this does not imply primary, secondary etc. as the specific positioning of coverages depends upon the episode of care.
Used in managing the coordination of benefits.
The insurer-specific identifier for the insurer-defined network of providers to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply.
Used in referral for treatment and in claims processing.
A suite of codes indicating the cost category and associated amount which have been detailed in the policy and may have been included on the health card.
For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.
Required by providers to manage financial transaction with the patient.
The category of patient centric costs associated with treatment.
For example visit, specialist visits, emergency, inpatient care, etc.
Needed to identify the category associated with the amount for the patient.
The types of services to which patient copayments are specified.
The amount or percentage due from the beneficiary
The amount due from the patient for the cost category.
Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.
Needed to identify the amount for the patient associated with the category.
A suite of codes indicating exceptions or reductions to patient costs and their effective periods.
Needed to identify the exception associated with the amount for the patient.
The types of exceptions from the part or full value of financial obligations such as copays.
The timeframe during when the exception is in force.
Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs.
When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs.
Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.
The policy(s) which constitute this insurance coverage.
To reference the legally binding contract between the policy holder and the insurer.