Magentus Practice Management FHIR Implementation Guide
1.2.16 - ci-build

Magentus Practice Management FHIR Implementation Guide - Local Development build (v1.2.16) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

## Resource Profile: Genie Coverage

Official URL: http://fhir.geniesolutions.io/StructureDefinition/gs-coverage | Version: 1.2.16
Draft as of 2024-08-15 | Computable Name: GSCoverage

Genie Coverage core profile

Usage:

- Derived from this Resource Profile: EOrders Coverage
- Use this Resource Profile: EBookings ServiceRequest, EBookings Theatre List, EOrders Diagnostic Request Base and EOrders Diagnostic Request
- Refer to this Resource Profile: EBookings ServiceRequest, EOrders Diagnostic Request Base, EOrders Diagnostic Request and Referral Request

### Formal Views of Profile Content

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

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

This structure is derived from AUBaseCoverage

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage | C | 0..* | AUBaseCoverage | Insurance or medical plan or a payment agreement diagnosticrequest-medicare-number-and-bulkbill: Using Bulk Billed requires a medicare number or IHI for the patient diagnosticrequest-DVA-number-and-DVA: Using DVA requires a DVA number for the patient
id | S | 1..1 | id | Unique resource identifier generated from genie bookings service or contained resource access number, e.g. 1
Slices for identifier |  | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber | An identifier intended for computation Slice: Unordered, Open by pattern:type
identifier:mcn | S | 0..1 | AUMedicareCardNumber | Medicare card number should be provided when Coverage type is PUBLICPOL (Bulk Billed)
value |  | 1..1 | string | Minimum length 10 digits, maximum length 11 digits with IRN
identifier:dva | S | 0..1 | AUDVANumber | DVA number should be provided when Coverage type is VET (DVA)
type |  | 1..1 | CodeableConcept | DVAU | DVG | DVO | DVW Binding: Genie DVA Entitlement ValueSet (required)
identifier:insurancemembernumber | S | 0..1 | AUInsuranceMemberNumber | Private insurance member number should be provided when Coverage type is HIP
type |  |  |  |
coding | S | 1..1 | Coding | Member number identifier type
system | S | 1..1 | uri | System identifier namespace for the insurer that assigned the insurance member number
value | S | 1..1 | string | Insurance member number
assigner |  |  |  |
display | S | 1..1 | string | Name of insurer
status | S | 1..1 | code | active | cancelled Binding: Genie Coverage Status values (required)
type | S | 1..1 | CodeableConcept | Coverage Type and Self Payment code Binding: Genie Coverage Type and Self Pay codes (required)
coding |  |  |  |
code |  | 0..1 | code | pay | PUBLICPOL | payconc | WCBPOL | HIP | VET | AUTOPOL
display |  | 0..1 | string | Pay | public healthcare | Concession | workers compensation | health insurance plan policy | veteran health program | automobile
text |  | 1..1 | string | Private (Self Funded) | Bulk Billed | Concession | Workcover | Private Insurance Plan | DVA | Motor Accident
beneficiary |  | 1..1 | Reference(Genie Patient) | Patient
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
payor |  | 1..1 | Reference(Organization | Patient | RelatedPerson) | Insurer of the policy (organization), or self funded payor (Patient or RelatedPerson)
reference | S | 0..1 | string | Patient reference when self funded
type |  | 0..1 | uri | Organization | Patient | RelatedPerson
identifier | S | 0..1 | Identifier | National insurer identifier
type |  | 0..1 | CodeableConcept | Description of identifier Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: NII
text |  | 0..1 | string | Plain text representation of the concept Required Pattern: National Insurer identifier
system |  | 0..1 | uri | The namespace for the identifier value Required Pattern: https://privatehealth.gov.au/dynamic/insurer
value |  | 1..1 | string | The value that is unique
display | S | 1..1 | string | Name of insurer or self funded payor
class |  | 0..1 | BackboneElement | Coverage classification
type |  | 1..1 | CodeableConcept | Plan type Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan
value | S | 1..1 | string | Class type
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Coverage.identifier:dva.type | required | GSDVAEntitlement `http://fhir.geniesolutions.io/ValueSet/gs-dva-entitlement` from this IG
Coverage.status | required | GSCoverageStatus `http://fhir.geniesolutions.io/ValueSet/gs-coverage-status` from this IG
Coverage.type | required | GSCoverageType `http://fhir.geniesolutions.io/ValueSet/gs-coverage-type` from this IG

#### Constraints

Id | Grade | Path(s) | Details | Requirements
diagnosticrequest-DVA-number-and-DVA | error | Coverage | Using DVA requires a DVA number for the patient : 'VET' in $this.type.coding.code implies $this.beneficiary.resolve().identifier.type.coding.where(code.memberOf('http://terminology.hl7.org.au/ValueSet/dva-entitlement')).exists() |
diagnosticrequest-medicare-number-and-bulkbill | error | Coverage | Using Bulk Billed requires a medicare number or IHI for the patient : 'PUBLICPOL' in $this.type.coding.code implies $this.beneficiary.resolve().identifier.type.coding.where(code = 'MC').exists() |

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage | C | 0..* | AUBaseCoverage | Insurance or medical plan or a payment agreement diagnosticrequest-medicare-number-and-bulkbill: Using Bulk Billed requires a medicare number or IHI for the patient diagnosticrequest-DVA-number-and-DVA: Using DVA requires a DVA number for the patient
id | S Σ | 1..1 | id | Unique resource identifier generated from genie bookings service or contained resource access number, e.g. 1
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 |  | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber | An identifier intended for computation Slice: Unordered, Open by pattern:type
identifier:mcn | S | 0..1 | AUMedicareCardNumber | Medicare card number should be provided when Coverage type is PUBLICPOL (Bulk Billed)
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 1..1 | CodeableConcept | Description of identifier 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
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MC
system | Σ | 1..1 | uri | The namespace for the identifier value Fixed Value: http://ns.electronichealth.net.au/id/medicare-number
value | Σ | 1..1 | string | Minimum length 10 digits, maximum length 11 digits with IRN Example General: 123456 Example Medicare card number: 32788511952 Max Length: 11
identifier:dva | S | 0..1 | AUDVANumber | DVA number should be provided when Coverage type is VET (DVA)
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 1..1 | CodeableConcept | DVAU | DVG | DVO | DVW Binding: Genie DVA Entitlement ValueSet (required)
system | Σ | 1..1 | uri | The namespace for the identifier value Fixed Value: http://ns.electronichealth.net.au/id/dva
value | Σ | 1..1 | string | DVA number Example General: 123456 Example DVA number: NBUR9080 Max Length: 9
identifier:insurancemembernumber | S | 0..1 | AUInsuranceMemberNumber | Private insurance member number should be provided when Coverage type is HIP
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 1..1 | CodeableConcept | Description of identifier 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
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB
coding | S Σ | 1..1 | Coding | Member number identifier type
system | S Σ | 1..1 | uri | System identifier namespace for the insurer that assigned the insurance member number Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | Insurance member number Example General: 123456
assigner | Σ | 1..1 | Reference(Organization) | Insurer
display | S Σ | 1..1 | string | Name of insurer
status | ?!S Σ | 1..1 | code | active | cancelled Binding: Genie Coverage Status values (required)
type | S Σ | 1..1 | CodeableConcept | Coverage Type and Self Payment code Binding: Genie Coverage Type and Self Pay codes (required)
text | Σ | 1..1 | string | Private (Self Funded) | Bulk Billed | Concession | Workcover | Private Insurance Plan | DVA | Motor Accident
beneficiary | Σ | 1..1 | Reference(Genie Patient) | Patient
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
payor | Σ | 1..1 | Reference(Organization | Patient | RelatedPerson) | Insurer of the policy (organization), or self funded payor (Patient or RelatedPerson)
reference | S Σ C | 0..1 | string | Patient reference when self funded
type | Σ | 0..1 | uri | Organization | Patient | RelatedPerson Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | S Σ | 0..1 | Identifier | National insurer identifier
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier 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
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: NII
text | Σ | 0..1 | string | Plain text representation of the concept Required Pattern: National Insurer identifier
system | Σ | 0..1 | uri | The namespace for the identifier value Required Pattern: https://privatehealth.gov.au/dynamic/insurer
value | Σ | 1..1 | string | The value that is unique Example General: 123456
display | S Σ | 1..1 | string | Name of insurer or self funded payor
class |  | 0..1 | BackboneElement | Coverage classification
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Plan type Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan
value | S Σ | 1..1 | string | Class type
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Coverage.identifier:mcn.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:mcn.type | extensible | Pattern: MC `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.identifier:dva.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:dva.type | required | GSDVAEntitlement `http://fhir.geniesolutions.io/ValueSet/gs-dva-entitlement` from this IG
Coverage.identifier:insurancemembernumber.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:insurancemembernumber.type | extensible | Pattern: MB `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.status | required | GSCoverageStatus `http://fhir.geniesolutions.io/ValueSet/gs-coverage-status` from this IG
Coverage.type | required | GSCoverageType `http://fhir.geniesolutions.io/ValueSet/gs-coverage-type` from this IG
Coverage.payor.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` from the FHIR Standard
Coverage.payor.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.payor.identifier.type | extensible | Pattern: NII `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.class.type | extensible | Pattern: plan `http://hl7.org/fhir/ValueSet/coverage-class` from the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
diagnosticrequest-DVA-number-and-DVA | error | Coverage | Using DVA requires a DVA number for the patient : 'VET' in $this.type.coding.code implies $this.beneficiary.resolve().identifier.type.coding.where(code.memberOf('http://terminology.hl7.org.au/ValueSet/dva-entitlement')).exists() |
diagnosticrequest-medicare-number-and-bulkbill | error | Coverage | Using Bulk Billed requires a medicare number or IHI for the patient : 'PUBLICPOL' in $this.type.coding.code implies $this.beneficiary.resolve().identifier.type.coding.where(code = 'MC').exists() |
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() |

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage | C | 0..* | AUBaseCoverage | Insurance or medical plan or a payment agreement diagnosticrequest-medicare-number-and-bulkbill: Using Bulk Billed requires a medicare number or IHI for the patient diagnosticrequest-DVA-number-and-DVA: Using DVA requires a DVA number for the patient
id | S Σ | 1..1 | id | Unique resource identifier generated from genie bookings service or contained resource access number, e.g. 1
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
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
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier |  | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber | An identifier intended for computation Slice: Unordered, Open by pattern:type
identifier:mcn | S | 0..1 | AUMedicareCardNumber | Medicare card number should be provided when Coverage type is PUBLICPOL (Bulk Billed)
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 | Σ | 1..1 | CodeableConcept | Description of identifier 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: MC
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 | 1..1 | uri | The namespace for the identifier value Fixed Value: http://ns.electronichealth.net.au/id/medicare-number
value | Σ | 1..1 | string | Minimum length 10 digits, maximum length 11 digits with IRN Example General: 123456 Example Medicare card number: 32788511952 Max Length: 11
period | Σ | 0..1 | Period | Time period when id is/was valid for use
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
start | Σ C | 0..1 | dateTime | Starting time with inclusive boundary
end | Σ C | 0..1 | dateTime | Medicare card expiry date
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
identifier:dva | S | 0..1 | AUDVANumber | DVA number should be provided when Coverage type is VET (DVA)
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 | Σ | 1..1 | CodeableConcept | DVAU | DVG | DVO | DVW Binding: Genie DVA Entitlement ValueSet (required)
system | Σ | 1..1 | uri | The namespace for the identifier value Fixed Value: http://ns.electronichealth.net.au/id/dva
value | Σ | 1..1 | string | DVA number Example General: 123456 Example DVA number: NBUR9080 Max Length: 9
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)
identifier:insurancemembernumber | S | 0..1 | AUInsuranceMemberNumber | Private insurance member number should be provided when Coverage type is HIP
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 | Σ | 1..1 | CodeableConcept | Description of identifier 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
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | S Σ | 1..1 | Coding | Member number identifier type
text | Σ | 0..1 | string | Plain text representation of the concept
system | S Σ | 1..1 | uri | System identifier namespace for the insurer that assigned the insurance member number Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | Insurance member number Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 1..1 | Reference(Organization) | Insurer
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | S Σ | 1..1 | string | Name of insurer
status | ?!S Σ | 1..1 | code | active | cancelled Binding: Genie Coverage Status values (required)
type | S Σ | 1..1 | CodeableConcept | Coverage Type and Self Payment code Binding: Genie Coverage Type and Self Pay codes (required)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | Σ | 0..1 | uri | Identity of the terminology system
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ | 0..1 | code | pay | PUBLICPOL | payconc | WCBPOL | HIP | VET | AUTOPOL
display | Σ | 0..1 | string | Pay | public healthcare | Concession | workers compensation | health insurance plan policy | veteran health program | automobile
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 1..1 | string | Private (Self Funded) | Bulk Billed | Concession | Workcover | Private Insurance Plan | DVA | Motor Accident
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(Genie Patient) | Patient
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
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..1 | Reference(Organization | Patient | RelatedPerson) | Insurer of the policy (organization), or self funded payor (Patient or RelatedPerson)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 0..1 | string | Patient reference when self funded
type | Σ | 0..1 | uri | Organization | Patient | RelatedPerson Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | S Σ | 0..1 | Identifier | National insurer identifier
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 | Σ | 0..1 | CodeableConcept | Description of identifier 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: NII
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
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | Σ | 0..1 | string | Plain text representation of the concept Required Pattern: National Insurer identifier
system | Σ | 0..1 | uri | The namespace for the identifier value Required Pattern: https://privatehealth.gov.au/dynamic/insurer
value | Σ | 1..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)
display | S Σ | 1..1 | string | Name of insurer or self funded payor
class |  | 0..1 | BackboneElement | Coverage classification
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 | Plan type 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 | S Σ | 1..1 | string | Class 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 / Code | URI
Coverage.language | preferred | CommonLanguages
Additional Bindings | Purpose
AllLanguages | Max Binding
`http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
Coverage.identifier:mcn.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:mcn.type | extensible | Pattern: MC `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.identifier:dva.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:dva.type | required | GSDVAEntitlement `http://fhir.geniesolutions.io/ValueSet/gs-dva-entitlement` from this IG
Coverage.identifier:insurancemembernumber.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:insurancemembernumber.type | extensible | Pattern: MB `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.identifier:insurancemembernumber.assigner.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` from the FHIR Standard
Coverage.status | required | GSCoverageStatus `http://fhir.geniesolutions.io/ValueSet/gs-coverage-status` from this IG
Coverage.type | required | GSCoverageType `http://fhir.geniesolutions.io/ValueSet/gs-coverage-type` from this IG
Coverage.beneficiary.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` from the FHIR Standard
Coverage.relationship | extensible | SubscriberRelationshipCodes `http://hl7.org/fhir/ValueSet/subscriber-relationship` from the FHIR Standard
Coverage.payor.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` from the FHIR Standard
Coverage.payor.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.payor.identifier.type | extensible | Pattern: NII `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.class.type | extensible | Pattern: plan `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
diagnosticrequest-DVA-number-and-DVA | error | Coverage | Using DVA requires a DVA number for the patient : 'VET' in $this.type.coding.code implies $this.beneficiary.resolve().identifier.type.coding.where(code.memberOf('http://terminology.hl7.org.au/ValueSet/dva-entitlement')).exists() |
diagnosticrequest-medicare-number-and-bulkbill | error | Coverage | Using Bulk Billed requires a medicare number or IHI for the patient : 'PUBLICPOL' in $this.type.coding.code implies $this.beneficiary.resolve().identifier.type.coding.where(code = 'MC').exists() |
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 AUBaseCoverage

Summary

Mandatory: 5 elements(2 nested mandatory elements)
Must-Support: 15 elements

Structures

This structure refers to these other structures:

- AU Medicare Card Number (http://hl7.org.au/fhir/StructureDefinition/au-medicarecardnumber)
- AU DVA Number (http://hl7.org.au/fhir/StructureDefinition/au-dvanumber)
- AU Insurance Member Number (http://hl7.org.au/fhir/StructureDefinition/au-insurancemembernumber)
- Genie Patient (http://fhir.geniesolutions.io/StructureDefinition/gs-patient)

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from AUBaseCoverage

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage | C | 0..* | AUBaseCoverage | Insurance or medical plan or a payment agreement diagnosticrequest-medicare-number-and-bulkbill: Using Bulk Billed requires a medicare number or IHI for the patient diagnosticrequest-DVA-number-and-DVA: Using DVA requires a DVA number for the patient
id | S | 1..1 | id | Unique resource identifier generated from genie bookings service or contained resource access number, e.g. 1
Slices for identifier |  | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber | An identifier intended for computation Slice: Unordered, Open by pattern:type
identifier:mcn | S | 0..1 | AUMedicareCardNumber | Medicare card number should be provided when Coverage type is PUBLICPOL (Bulk Billed)
value |  | 1..1 | string | Minimum length 10 digits, maximum length 11 digits with IRN
identifier:dva | S | 0..1 | AUDVANumber | DVA number should be provided when Coverage type is VET (DVA)
type |  | 1..1 | CodeableConcept | DVAU | DVG | DVO | DVW Binding: Genie DVA Entitlement ValueSet (required)
identifier:insurancemembernumber | S | 0..1 | AUInsuranceMemberNumber | Private insurance member number should be provided when Coverage type is HIP
type |  |  |  |
coding | S | 1..1 | Coding | Member number identifier type
system | S | 1..1 | uri | System identifier namespace for the insurer that assigned the insurance member number
value | S | 1..1 | string | Insurance member number
assigner |  |  |  |
display | S | 1..1 | string | Name of insurer
status | S | 1..1 | code | active | cancelled Binding: Genie Coverage Status values (required)
type | S | 1..1 | CodeableConcept | Coverage Type and Self Payment code Binding: Genie Coverage Type and Self Pay codes (required)
coding |  |  |  |
code |  | 0..1 | code | pay | PUBLICPOL | payconc | WCBPOL | HIP | VET | AUTOPOL
display |  | 0..1 | string | Pay | public healthcare | Concession | workers compensation | health insurance plan policy | veteran health program | automobile
text |  | 1..1 | string | Private (Self Funded) | Bulk Billed | Concession | Workcover | Private Insurance Plan | DVA | Motor Accident
beneficiary |  | 1..1 | Reference(Genie Patient) | Patient
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
payor |  | 1..1 | Reference(Organization | Patient | RelatedPerson) | Insurer of the policy (organization), or self funded payor (Patient or RelatedPerson)
reference | S | 0..1 | string | Patient reference when self funded
type |  | 0..1 | uri | Organization | Patient | RelatedPerson
identifier | S | 0..1 | Identifier | National insurer identifier
type |  | 0..1 | CodeableConcept | Description of identifier Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: NII
text |  | 0..1 | string | Plain text representation of the concept Required Pattern: National Insurer identifier
system |  | 0..1 | uri | The namespace for the identifier value Required Pattern: https://privatehealth.gov.au/dynamic/insurer
value |  | 1..1 | string | The value that is unique
display | S | 1..1 | string | Name of insurer or self funded payor
class |  | 0..1 | BackboneElement | Coverage classification
type |  | 1..1 | CodeableConcept | Plan type Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan
value | S | 1..1 | string | Class type
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Coverage.identifier:dva.type | required | GSDVAEntitlement `http://fhir.geniesolutions.io/ValueSet/gs-dva-entitlement` from this IG
Coverage.status | required | GSCoverageStatus `http://fhir.geniesolutions.io/ValueSet/gs-coverage-status` from this IG
Coverage.type | required | GSCoverageType `http://fhir.geniesolutions.io/ValueSet/gs-coverage-type` from this IG

#### Constraints

Id | Grade | Path(s) | Details | Requirements
diagnosticrequest-DVA-number-and-DVA | error | Coverage | Using DVA requires a DVA number for the patient : 'VET' in $this.type.coding.code implies $this.beneficiary.resolve().identifier.type.coding.where(code.memberOf('http://terminology.hl7.org.au/ValueSet/dva-entitlement')).exists() |
diagnosticrequest-medicare-number-and-bulkbill | error | Coverage | Using Bulk Billed requires a medicare number or IHI for the patient : 'PUBLICPOL' in $this.type.coding.code implies $this.beneficiary.resolve().identifier.type.coding.where(code = 'MC').exists() |

Key Elements View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage | C | 0..* | AUBaseCoverage | Insurance or medical plan or a payment agreement diagnosticrequest-medicare-number-and-bulkbill: Using Bulk Billed requires a medicare number or IHI for the patient diagnosticrequest-DVA-number-and-DVA: Using DVA requires a DVA number for the patient
id | S Σ | 1..1 | id | Unique resource identifier generated from genie bookings service or contained resource access number, e.g. 1
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 |  | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber | An identifier intended for computation Slice: Unordered, Open by pattern:type
identifier:mcn | S | 0..1 | AUMedicareCardNumber | Medicare card number should be provided when Coverage type is PUBLICPOL (Bulk Billed)
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 1..1 | CodeableConcept | Description of identifier 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
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MC
system | Σ | 1..1 | uri | The namespace for the identifier value Fixed Value: http://ns.electronichealth.net.au/id/medicare-number
value | Σ | 1..1 | string | Minimum length 10 digits, maximum length 11 digits with IRN Example General: 123456 Example Medicare card number: 32788511952 Max Length: 11
identifier:dva | S | 0..1 | AUDVANumber | DVA number should be provided when Coverage type is VET (DVA)
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 1..1 | CodeableConcept | DVAU | DVG | DVO | DVW Binding: Genie DVA Entitlement ValueSet (required)
system | Σ | 1..1 | uri | The namespace for the identifier value Fixed Value: http://ns.electronichealth.net.au/id/dva
value | Σ | 1..1 | string | DVA number Example General: 123456 Example DVA number: NBUR9080 Max Length: 9
identifier:insurancemembernumber | S | 0..1 | AUInsuranceMemberNumber | Private insurance member number should be provided when Coverage type is HIP
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 1..1 | CodeableConcept | Description of identifier 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
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB
coding | S Σ | 1..1 | Coding | Member number identifier type
system | S Σ | 1..1 | uri | System identifier namespace for the insurer that assigned the insurance member number Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | Insurance member number Example General: 123456
assigner | Σ | 1..1 | Reference(Organization) | Insurer
display | S Σ | 1..1 | string | Name of insurer
status | ?!S Σ | 1..1 | code | active | cancelled Binding: Genie Coverage Status values (required)
type | S Σ | 1..1 | CodeableConcept | Coverage Type and Self Payment code Binding: Genie Coverage Type and Self Pay codes (required)
text | Σ | 1..1 | string | Private (Self Funded) | Bulk Billed | Concession | Workcover | Private Insurance Plan | DVA | Motor Accident
beneficiary | Σ | 1..1 | Reference(Genie Patient) | Patient
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
payor | Σ | 1..1 | Reference(Organization | Patient | RelatedPerson) | Insurer of the policy (organization), or self funded payor (Patient or RelatedPerson)
reference | S Σ C | 0..1 | string | Patient reference when self funded
type | Σ | 0..1 | uri | Organization | Patient | RelatedPerson Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | S Σ | 0..1 | Identifier | National insurer identifier
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier 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
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: NII
text | Σ | 0..1 | string | Plain text representation of the concept Required Pattern: National Insurer identifier
system | Σ | 0..1 | uri | The namespace for the identifier value Required Pattern: https://privatehealth.gov.au/dynamic/insurer
value | Σ | 1..1 | string | The value that is unique Example General: 123456
display | S Σ | 1..1 | string | Name of insurer or self funded payor
class |  | 0..1 | BackboneElement | Coverage classification
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Plan type Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan
value | S Σ | 1..1 | string | Class type
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Coverage.identifier:mcn.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:mcn.type | extensible | Pattern: MC `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.identifier:dva.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:dva.type | required | GSDVAEntitlement `http://fhir.geniesolutions.io/ValueSet/gs-dva-entitlement` from this IG
Coverage.identifier:insurancemembernumber.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:insurancemembernumber.type | extensible | Pattern: MB `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.status | required | GSCoverageStatus `http://fhir.geniesolutions.io/ValueSet/gs-coverage-status` from this IG
Coverage.type | required | GSCoverageType `http://fhir.geniesolutions.io/ValueSet/gs-coverage-type` from this IG
Coverage.payor.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` from the FHIR Standard
Coverage.payor.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.payor.identifier.type | extensible | Pattern: NII `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.class.type | extensible | Pattern: plan `http://hl7.org/fhir/ValueSet/coverage-class` from the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
diagnosticrequest-DVA-number-and-DVA | error | Coverage | Using DVA requires a DVA number for the patient : 'VET' in $this.type.coding.code implies $this.beneficiary.resolve().identifier.type.coding.where(code.memberOf('http://terminology.hl7.org.au/ValueSet/dva-entitlement')).exists() |
diagnosticrequest-medicare-number-and-bulkbill | error | Coverage | Using Bulk Billed requires a medicare number or IHI for the patient : 'PUBLICPOL' in $this.type.coding.code implies $this.beneficiary.resolve().identifier.type.coding.where(code = 'MC').exists() |
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() |

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage | C | 0..* | AUBaseCoverage | Insurance or medical plan or a payment agreement diagnosticrequest-medicare-number-and-bulkbill: Using Bulk Billed requires a medicare number or IHI for the patient diagnosticrequest-DVA-number-and-DVA: Using DVA requires a DVA number for the patient
id | S Σ | 1..1 | id | Unique resource identifier generated from genie bookings service or contained resource access number, e.g. 1
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
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
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier |  | 0..* | Identifier, AUMedicareCardNumber, AUDVANumber, AUInsuranceMemberNumber | An identifier intended for computation Slice: Unordered, Open by pattern:type
identifier:mcn | S | 0..1 | AUMedicareCardNumber | Medicare card number should be provided when Coverage type is PUBLICPOL (Bulk Billed)
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 | Σ | 1..1 | CodeableConcept | Description of identifier 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: MC
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 | 1..1 | uri | The namespace for the identifier value Fixed Value: http://ns.electronichealth.net.au/id/medicare-number
value | Σ | 1..1 | string | Minimum length 10 digits, maximum length 11 digits with IRN Example General: 123456 Example Medicare card number: 32788511952 Max Length: 11
period | Σ | 0..1 | Period | Time period when id is/was valid for use
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
start | Σ C | 0..1 | dateTime | Starting time with inclusive boundary
end | Σ C | 0..1 | dateTime | Medicare card expiry date
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
identifier:dva | S | 0..1 | AUDVANumber | DVA number should be provided when Coverage type is VET (DVA)
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 | Σ | 1..1 | CodeableConcept | DVAU | DVG | DVO | DVW Binding: Genie DVA Entitlement ValueSet (required)
system | Σ | 1..1 | uri | The namespace for the identifier value Fixed Value: http://ns.electronichealth.net.au/id/dva
value | Σ | 1..1 | string | DVA number Example General: 123456 Example DVA number: NBUR9080 Max Length: 9
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)
identifier:insurancemembernumber | S | 0..1 | AUInsuranceMemberNumber | Private insurance member number should be provided when Coverage type is HIP
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 | Σ | 1..1 | CodeableConcept | Description of identifier 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
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | S Σ | 1..1 | Coding | Member number identifier type
text | Σ | 0..1 | string | Plain text representation of the concept
system | S Σ | 1..1 | uri | System identifier namespace for the insurer that assigned the insurance member number Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | Insurance member number Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 1..1 | Reference(Organization) | Insurer
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | S Σ | 1..1 | string | Name of insurer
status | ?!S Σ | 1..1 | code | active | cancelled Binding: Genie Coverage Status values (required)
type | S Σ | 1..1 | CodeableConcept | Coverage Type and Self Payment code Binding: Genie Coverage Type and Self Pay codes (required)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | Σ | 0..1 | uri | Identity of the terminology system
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ | 0..1 | code | pay | PUBLICPOL | payconc | WCBPOL | HIP | VET | AUTOPOL
display | Σ | 0..1 | string | Pay | public healthcare | Concession | workers compensation | health insurance plan policy | veteran health program | automobile
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 1..1 | string | Private (Self Funded) | Bulk Billed | Concession | Workcover | Private Insurance Plan | DVA | Motor Accident
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(Genie Patient) | Patient
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
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..1 | Reference(Organization | Patient | RelatedPerson) | Insurer of the policy (organization), or self funded payor (Patient or RelatedPerson)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 0..1 | string | Patient reference when self funded
type | Σ | 0..1 | uri | Organization | Patient | RelatedPerson Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | S Σ | 0..1 | Identifier | National insurer identifier
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 | Σ | 0..1 | CodeableConcept | Description of identifier 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: NII
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
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | Σ | 0..1 | string | Plain text representation of the concept Required Pattern: National Insurer identifier
system | Σ | 0..1 | uri | The namespace for the identifier value Required Pattern: https://privatehealth.gov.au/dynamic/insurer
value | Σ | 1..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)
display | S Σ | 1..1 | string | Name of insurer or self funded payor
class |  | 0..1 | BackboneElement | Coverage classification
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 | Plan type 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 | S Σ | 1..1 | string | Class 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 / Code | URI
Coverage.language | preferred | CommonLanguages
Additional Bindings | Purpose
AllLanguages | Max Binding
`http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
Coverage.identifier:mcn.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:mcn.type | extensible | Pattern: MC `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.identifier:dva.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:dva.type | required | GSDVAEntitlement `http://fhir.geniesolutions.io/ValueSet/gs-dva-entitlement` from this IG
Coverage.identifier:insurancemembernumber.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:insurancemembernumber.type | extensible | Pattern: MB `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.identifier:insurancemembernumber.assigner.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` from the FHIR Standard
Coverage.status | required | GSCoverageStatus `http://fhir.geniesolutions.io/ValueSet/gs-coverage-status` from this IG
Coverage.type | required | GSCoverageType `http://fhir.geniesolutions.io/ValueSet/gs-coverage-type` from this IG
Coverage.beneficiary.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` from the FHIR Standard
Coverage.relationship | extensible | SubscriberRelationshipCodes `http://hl7.org/fhir/ValueSet/subscriber-relationship` from the FHIR Standard
Coverage.payor.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` from the FHIR Standard
Coverage.payor.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.payor.identifier.type | extensible | Pattern: NII `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.class.type | extensible | Pattern: plan `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
diagnosticrequest-DVA-number-and-DVA | error | Coverage | Using DVA requires a DVA number for the patient : 'VET' in $this.type.coding.code implies $this.beneficiary.resolve().identifier.type.coding.where(code.memberOf('http://terminology.hl7.org.au/ValueSet/dva-entitlement')).exists() |
diagnosticrequest-medicare-number-and-bulkbill | error | Coverage | Using Bulk Billed requires a medicare number or IHI for the patient : 'PUBLICPOL' in $this.type.coding.code implies $this.beneficiary.resolve().identifier.type.coding.where(code = 'MC').exists() |
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 AUBaseCoverage

Summary

Mandatory: 5 elements(2 nested mandatory elements)
Must-Support: 15 elements

Structures

This structure refers to these other structures:

- AU Medicare Card Number (http://hl7.org.au/fhir/StructureDefinition/au-medicarecardnumber)
- AU DVA Number (http://hl7.org.au/fhir/StructureDefinition/au-dvanumber)
- AU Insurance Member Number (http://hl7.org.au/fhir/StructureDefinition/au-insurancemembernumber)
- Genie Patient (http://fhir.geniesolutions.io/StructureDefinition/gs-patient)

Slices

This structure defines the following Slices:

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

Other representations of profile: CSV, Excel, Schematron