Das Basisprofile für die Ressource Coverage stellt die Mindestanforderungen für die Abbildung eines Versicherungsverhältnisses - unabhängig von dessen Art - dar.
Alle spezialisierten Coverage-Profile sind von diesem Basisprofil abgeleitet.
Für Versicherungsverhältnisse, die kein spezialisiertes Profil haben, sollte das Basisprofil verwendet werden.
| Coverage | 0..* | Coverage | Element IdCoverage Versicherungsdaten DefinitionAngaben zur Versicherung oder zur Kostenübernahme durch den Patienten selbst oder durch Dritte. The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.
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| identifier | Σ | 0..* | Identifier | Element IdCoverage.identifier Business Identifier for the coverage DefinitionA unique identifier assigned to this coverage. Allows coverages to be distinguished and referenced. 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.
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| status | Σ ?! | 1..1 | codeBinding | Element IdCoverage.status active | cancelled | draft | entered-in-error DefinitionThe status of the resource instance. 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 labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.
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| type | Σ | 1..1 | CodeableConceptBinding | Element IdCoverage.type Versicherungsart DefinitionArt der Versicherung: Selbstzahler, gesetzliche/private Versicherung, Berufsgenossenschaft oder Sozialamt The order of application of coverages is dependent on the types of coverage. 28.07.2017 (zulip): TC Konsens bzgl. Verwendung eines eigenen ValueSets anstelle des im Standrad definierten preferred bindings, da die dort igen Codes nicht passen. VersicherungsartDeBasis (required) Constraints
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| policyHolder | Σ | 0..0 | Reference(Patient| RelatedPerson| Organization) | Element IdCoverage.policyHolder Owner of the policy DefinitionThe party who 'owns' the insurance policy. This provides employer information in the case of Worker's Compensation and other policies. Es gibt derzeit in DE keine Verwendung für dieses Attribut (Konsens Interop-Forum 12.6.2017) Falls es UseCases gibt, die dieses Attribut benötigen, bitte Info auf chat.fhir.org Reference(Patient| RelatedPerson| Organization) Constraints
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| subscriber | Σ | 0..1 | Reference(Patient| RelatedPerson) | Element IdCoverage.subscriber Hauptversicherte Person / Mitglied DefinitionHauptversicherte Person (ggf. abweichend von beneficiary), z.B. bei Familienversicherung This is the party who is entitled to the benfits under the policy. May be self or a parent in the case of dependants. Reference(Patient| RelatedPerson) Constraints
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| subscriberId | Σ | 0..0 | string | Element IdCoverage.subscriberId ID assigned to the subscriber DefinitionThe insurer assigned ID for the Subscriber. The insurer requires this identifier on correspondance and claims (digital and otherwise). Note that FHIR strings SHALL NOT exceed 1MB in size
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| beneficiary | Σ | 1..1 | Reference(Patient) | Element IdCoverage.beneficiary Begünstigte Person DefinitionPerson, auf die sich die Kostenübernahme bezieht (der Patient) This is the party who receives treatment for which the costs are reimbursed under the coverage. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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| dependent | Σ | 0..1 | string | Element IdCoverage.dependent Dependent number DefinitionA unique identifier for a dependent under the coverage. For some coverages a single identifier is issued to the Subscriber and then a unique dependent number is issued to each beneficiary. Periodically the member number is constructed from the subscriberId and the dependant number.
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| relationship | 0..1 | CodeableConceptBinding | Element IdCoverage.relationship Beneficiary relationship to the subscriber DefinitionThe relationship of beneficiary (patient) to the subscriber. To determine relationship between the patient and the subscriber to determine coordination of benefits. Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others. subscriber-relationship (extensible) Constraints
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| period | Σ | 0..1 | Period | Element IdCoverage.period Coverage start and end dates DefinitionTime 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. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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| payor | Σ | 1..* | Reference(Organization| Patient| RelatedPerson) | Element IdCoverage.payor Versicherer DefinitionVersicherer, der die Police ausgegeben hat oder Persopn/Organisation, die die Kosten übernimmt. Need to identify the issuer to target for claim processing and for coordination of benefit processing. 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. Reference(Organization| Patient| RelatedPerson) Constraints
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| class | 0..* | BackboneElement | Element IdCoverage.class Additional coverage classifications DefinitionA suite of underwriter specific classifiers. The codes provided on the health card which identify or confirm the specific policy for the insurer. For example may be used to identify a class of coverage or employer group, Policy, Plan.
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| type | Σ | 1..1 | CodeableConceptBinding | Element IdCoverage.class.type Type of class such as 'group' or 'plan' DefinitionThe 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| value | Σ | 1..1 | string | Element IdCoverage.class.value Value associated with the type DefinitionThe alphanumeric string value associated with the insurer issued label. The insurer issued label and value are necessary to identify the specific policy. For example, the Group or Plan number.
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| name | Σ | 0..1 | string | Element IdCoverage.class.name Human readable description of the type and value DefinitionA short description for the class. Used to provide a meaningful description in correspondence to the patient. Note that FHIR strings SHALL NOT exceed 1MB in size
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| order | Σ | 0..0 | positiveInt | Element IdCoverage.order Relative order of the coverage DefinitionThe 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. Es git derzeit in DE keine Verwendung für dieses Attribut (Konsens Interop-Forum 12.6.2017) Für die Priorisierung der Versicherungsverhältnisse sollte statt dessen Account.coverage.priority verwendet werden, da die Priorisierung abhängig von Fall- und Abrechnungsart unterschiedlich sein kann. Falls es UseCases gibt, die dieses Attribut benötigen, bitte Info auf chat.fhir.org
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| network | Σ | 0..0 | string | Element IdCoverage.network Insurer network DefinitionDie Versicherungsleistungen sind an ein bestimmtes Netzwerk von Gesundheitsdienstleistern gebunden Used in referral for treatment and in claims processing. Es gibt derzeit in DE keine Verwendung für dieses Attribut (Konsens Interop-Forum 12.6.2017) Falls es UseCases gibt, die dieses Attribut benötigen, bitte Info auf chat.fhir.org
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| costToBeneficiary | 0..* | BackboneElement | Element IdCoverage.costToBeneficiary Patient payments for services/products Alternate namesCoPay, Deductible, Exceptions DefinitionA 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. Required by providers to manage financial transaction with the patient. For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.
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| type | Σ | 0..1 | CodeableConceptBinding | Element IdCoverage.costToBeneficiary.type Cost category DefinitionThe category of patient centric costs associated with treatment. Needed to identify the category associated with the amount for the patient. For example visit, specialist visits, emergency, inpatient care, etc. coverage-copay-type (extensible) Constraints
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| value[x] | Σ | 1..1 | Element IdCoverage.costToBeneficiary.value[x] The amount or percentage due from the beneficiary DefinitionThe amount due from the patient for the cost category. Needed to identify the amount for the patient associated with the category. Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.
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| valueQuantity | SimpleQuantity | Data Type | ||
| valueMoney | Money | Data Type | ||
| exception | 0..* | BackboneElement | Element IdCoverage.costToBeneficiary.exception Exceptions for patient payments DefinitionA suite of codes indicating exceptions or reductions to patient costs and their effective periods. Required by providers to manage financial transaction with the patient.
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| type | Σ | 1..1 | CodeableConcept | Element IdCoverage.costToBeneficiary.exception.type Exception category DefinitionThe code for the specific exception. Needed to identify the exception associated with the amount for the patient. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. coverage-financial-exception (example) Constraints
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| period | Σ | 0..1 | Period | Element IdCoverage.costToBeneficiary.exception.period The effective period of the exception DefinitionThe timeframe during when the exception is in force. Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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| subrogation | 0..1 | boolean | Element IdCoverage.subrogation Reimbursement to insurer DefinitionWhen 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs. See definition for when to be used. Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.
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| contract | 0..* | Reference(Contract) | Element IdCoverage.contract Contract details DefinitionThe policy(s) which constitute this insurance coverage. To reference the legally binding contract between the policy holder and the insurer. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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Für die Angabe der Versicherungsart wurde folgendes ValueSet abgestimmt:
| Version | 0.9 |
| Published by | HL7 Deutschland e.V. (Technisches Komitee FHIR) |
| Status | Draft (since 2017-09-15) |
| Experimental | True |
ValueSet für die in Deutschland üblichen Versicherungsarten
Other: http://hl7.de/technische-komitees/fhir/
This value set includes codes from the following code systems:| Code | System | Display |
|---|---|---|
| GKV | http://fhir.de/CodeSystem/versicherungsart-de-basis | gesetzliche Krankenversicherung |
| PKV | http://fhir.de/CodeSystem/versicherungsart-de-basis | private Krankenversicherung |
| BG | http://fhir.de/CodeSystem/versicherungsart-de-basis | Berufsgenossenschaft |
| SEL | http://fhir.de/CodeSystem/versicherungsart-de-basis | Selbstzahler |
| SOZ | http://fhir.de/CodeSystem/versicherungsart-de-basis | Sozialamt |
| GPV | http://fhir.de/CodeSystem/versicherungsart-de-basis | gesetzliche Pflegeversicherung |
| PPV | http://fhir.de/CodeSystem/versicherungsart-de-basis | private Pflegeversicherung |
| BEI | http://fhir.de/CodeSystem/versicherungsart-de-basis | Beihilfe |
Für die Abbildung eines gesetzlichen Versicherungsverhältnisses sind die Informationen auf der elektronischen Versichertenkarte (eGK) maßgeblich.
Diese Informationen werden über spezielle Extensions abgebildet, die Informationen den Einlesevorgang der eKG sowie dem Inhalt des darauf gespeicherten Datensatzes enthalten:
| Coverage | 0..* | Coverage | Element IdCoverage Versicherungsdaten DefinitionKostenübernahme im Rahmen eines gesetzlichen Versicherungsverhältnisses in Deutschland. The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.
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| extension | 0..* | Extension | Element IdCoverage.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Constraints
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| einlesedatumKarte | 0..1 | Extension(dateTime) | Element IdCoverage.extension:einlesedatumKarte Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. http://fhir.de/StructureDefinition/gkv/einlesedatum-karte Constraints
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| onlinepruefung | 0..1 | Extension(Complex) | Element IdCoverage.extension:onlinepruefung Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. Extension(Complex) Extension URLhttp://fhir.de/StructureDefinition/gkv/onlinepruefung-egk Constraints
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| versionEgk | 0..1 | Extension | Element IdCoverage.extension:versionEgk Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. http://fhir.de/StructureDefinition/gkv/version-vsdm Constraints
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| generationEgk | 0..* | Extension(string) | Element IdCoverage.extension:generationEgk eGK Generation ( 1 | 1+ | 2 ) Alternate namesextensions, user content DefinitionAngabe der Generation der Versichertenkarte 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. http://fhir.de/StructureDefinition/gkv/generation-egk Constraints
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| versichertenart | 0..1 | Extension(code) | Element IdCoverage.extension:versichertenart Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. http://fhir.de/StructureDefinition/gkv/versichertenart Constraints
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| kostenerstattung | 0..1 | Extension(Complex) | Element IdCoverage.extension:kostenerstattung Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. Extension(Complex) Extension URLhttp://fhir.de/StructureDefinition/gkv/kostenerstattung Constraints
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| wop | 0..1 | Extension(Coding) | Element IdCoverage.extension:wop Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. http://fhir.de/StructureDefinition/gkv/wop Constraints
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| besonderePersonengruppe | 0..1 | Extension(Coding) | Element IdCoverage.extension:besonderePersonengruppe Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. http://fhir.de/StructureDefinition/gkv/besondere-personengruppe Constraints
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| dmpKennzeichen | 0..1 | Extension(Coding) | Element IdCoverage.extension:dmpKennzeichen Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. http://fhir.de/StructureDefinition/gkv/dmp-kennzeichen Constraints
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| ruhenderLeistungsanspruch | 0..1 | Extension(Complex) | Element IdCoverage.extension:ruhenderLeistungsanspruch Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. Extension(Complex) Extension URLhttp://fhir.de/StructureDefinition/gkv/ruhender-leistungsanspruch Constraints
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| zuzahlungsstatus | 0..1 | Extension(Complex) | Element IdCoverage.extension:zuzahlungsstatus Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. Extension(Complex) Extension URLhttp://fhir.de/StructureDefinition/gkv/zuzahlungsstatus Constraints
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| identifier | Σ | 1..* | Identifier | Element IdCoverage.identifier Primärer Identifier der Versicherung DefinitionEin gesetzliches Versicherungsverhältnis sollte stets durch die eindeutige 30-stellige Versichertennummer identifiziert werden. Ist diese nicht bekannt, so wird die 10-stellige VersichertenID statt dessen verwendet. Allows coverages to be distinguished and referenced. TODO: Constraint, der prüft, dass mindestens entweder eine VersichertenID oder eine Krankenversichertennummer angegeben wurde. Unordered, Open, by system(Value) Constraints
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| KrankenversichertenID | Σ | 0..1 | Identifier-Profil für die 10-stellige Krankenversichertennummer | Element IdCoverage.identifier:KrankenversichertenID An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. Allows coverages to be distinguished and referenced. 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. Identifier-Profil für die 10-stellige Krankenversichertennummer Constraints
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| pseudo-Krankenversichertennummer | Σ | 0..1 | Identifier-Profil für die pseudonymisierte Krankenversichertennummer | Element IdCoverage.identifier:pseudo-Krankenversichertennummer pseudonymisierte Krankenversichertennummer DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. Allows coverages to be distinguished and referenced. 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. Identifier-Profil für die pseudonymisierte Krankenversichertennummer Constraints
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| status | Σ ?! | 1..1 | codeBinding | Element IdCoverage.status active | cancelled | draft | entered-in-error DefinitionThe status of the resource instance. 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 labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.
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| type | Σ | 1..1 | CodeableConceptBinding | Element IdCoverage.type Versicherungsart DefinitionArt der Versicherung: Selbstzahler, gesetzliche/private Versicherung, Berufsgenossenschaft oder Sozialamt The order of application of coverages is dependent on the types of coverage. 28.07.2017 (zulip): TC Konsens bzgl. Verwendung eines eigenen ValueSets anstelle des im Standrad definierten preferred bindings, da die dortigen Codes nicht passen. VersicherungsartDeBasis (required) Constraints
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| coding | Σ | 1..* | Coding | Element IdCoverage.type.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| system | Σ | 1..1 | uriFixed Value | Element IdCoverage.type.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://fhir.de/CodeSystem/versicherungsart-de-basis
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| version | Σ | 0..1 | string | Element IdCoverage.type.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | codeFixed Value | Element IdCoverage.type.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
GKV
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| display | Σ | 0..1 | string | Element IdCoverage.type.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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| userSelected | Σ | 0..1 | boolean | Element IdCoverage.type.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | Element IdCoverage.type.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| policyHolder | Σ | 0..0 | Reference(Patient| RelatedPerson| Organization) | Element IdCoverage.policyHolder Owner of the policy DefinitionThe party who 'owns' the insurance policy. This provides employer information in the case of Worker's Compensation and other policies. Es gibt derzeit in DE keine Verwendung für dieses Attribut (Konsens Interop-Forum 12.6.2017) Falls es UseCases gibt, die dieses Attribut benötigen, bitte Info auf chat.fhir.org Reference(Patient| RelatedPerson| Organization) Constraints
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| subscriber | Σ | 0..1 | Reference(Patient| RelatedPerson) | Element IdCoverage.subscriber Hauptversicherte Person / Mitglied DefinitionHauptversicherte Person (ggf. abweichend von beneficiary), z.B. bei Familienversicherung This is the party who is entitled to the benfits under the policy. May be self or a parent in the case of dependants. Reference(Patient| RelatedPerson) Constraints
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| reference | Σ | 0..1 | string | Element IdCoverage.subscriber.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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| type | Σ | 0..1 | uriBinding | Element IdCoverage.subscriber.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
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| identifier | Σ | 0..1 | Identifier | Element IdCoverage.subscriber.identifier VersichertenID (10-stellig) des Hauptversicherten DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
{
"system": "http://fhir.de/NamingSystem/gkv/kvid-10"
}
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| display | Σ | 0..1 | string | Element IdCoverage.subscriber.display Name des Hauptversicherten DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| subscriberId | Σ | 0..0 | string | Element IdCoverage.subscriberId ID assigned to the subscriber DefinitionThe insurer assigned ID for the Subscriber. The insurer requires this identifier on correspondance and claims (digital and otherwise). Note that FHIR strings SHALL NOT exceed 1MB in size
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| beneficiary | Σ | 1..1 | Reference(Patient) | Element IdCoverage.beneficiary Begünstigte Person DefinitionPerson, auf die sich die Kostenübernahme bezieht (der Patient) This is the party who receives treatment for which the costs are reimbursed under the coverage. Die Angabe der 10-stelligen Krankenversichertennummer ist verpflichtend. Durch die Referenz auf eine Patient-Resource können weitere Informationen zum Patienten hinterlegt werden.
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| reference | Σ | 0..1 | string | Element IdCoverage.beneficiary.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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| type | Σ | 0..1 | uriBinding | Element IdCoverage.beneficiary.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
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| identifier | Σ | 0..1 | Identifier | Element IdCoverage.beneficiary.identifier Identifier der versicherten Person DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
{
"system": "http://fhir.de/NamingSystem/gkv/kvid-10"
}
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| display | Σ | 0..1 | string | Element IdCoverage.beneficiary.display Name der Versicherten Person DefinitionDie Angabe des Namens des Versicherten dient der geeigenten Darstellung für den Benutzer und hat keine technische Bedeutung. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| dependent | Σ | 0..1 | string | Element IdCoverage.dependent Dependent number DefinitionA unique identifier for a dependent under the coverage. For some coverages a single identifier is issued to the Subscriber and then a unique dependent number is issued to each beneficiary. Periodically the member number is constructed from the subscriberId and the dependant number.
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| relationship | 0..1 | CodeableConceptBinding | Element IdCoverage.relationship Beneficiary relationship to the subscriber DefinitionThe relationship of beneficiary (patient) to the subscriber. To determine relationship between the patient and the subscriber to determine coordination of benefits. Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others. subscriber-relationship (extensible) Constraints
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| period | Σ | 0..1 | Period | Element IdCoverage.period Coverage start and end dates DefinitionTime 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. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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| start | Σ | 0..1 | dateTime | Element IdCoverage.period.start Starting time with inclusive boundary DefinitionThe start of the period. The boundary is inclusive. If the low element is missing, the meaning is that the low boundary is not known.
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| end | Σ | 0..1 | dateTime | Element IdCoverage.period.end End time with inclusive boundary, if not ongoing DefinitionThe 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.
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| payor | Σ | 1..2 | Reference(http://fhir.de/StructureDefinition/organization-de-basis) | Element IdCoverage.payor Versicherer DefinitionGibt den Kostenträger des Versicherten an. Die Angabe der IK-Nummer als logische Referenz sowie des Namens als Display ist zwingend erforderlich. Die Referenz auf eine Resource vom Typ Organization, die weitere Details zur Versicherung enthalten kann (z.B. Adresse, Kontaktdaten) ist optional. Sofern eine zweite Referenz auf einen Kostenträger existiert, so handelt es sich hierbei um den abrechnenden Kostenträger Need to identify the issuer to target for claim processing and for coordination of benefit processing. Die Angabe der IK-Nummer des Versicherers in payor.identifier ist verpflichtend. Weitere Angaben zum Versicherer (Name, Adresse) können in einer Organization-Resource hinterlegt werden, auf die hier referenziert wird. Reference(http://fhir.de/StructureDefinition/organization-de-basis) Constraints
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| reference | Σ | 0..1 | string | Element IdCoverage.payor.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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| type | Σ | 0..1 | uriBinding | Element IdCoverage.payor.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
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| identifier | Σ | 0..1 | Identifier | Element IdCoverage.payor.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). Unordered, Open, by system(Value) Constraints
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| sliceIdentifier | Σ | 0..* | Identifier-Profil für die Abbildung eines Instituskennzeichen | Element IdCoverage.payor.identifier:sliceIdentifier An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). Identifier-Profil für die Abbildung eines Instituskennzeichen Constraints
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| display | Σ | 1..1 | string | Element IdCoverage.payor.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| class | 0..* | BackboneElement | Element IdCoverage.class Additional coverage classifications DefinitionA suite of underwriter specific classifiers. The codes provided on the health card which identify or confirm the specific policy for the insurer. For example may be used to identify a class of coverage or employer group, Policy, Plan.
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| type | Σ | 1..1 | CodeableConceptBinding | Element IdCoverage.class.type Type of class such as 'group' or 'plan' DefinitionThe 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| value | Σ | 1..1 | string | Element IdCoverage.class.value Value associated with the type DefinitionThe alphanumeric string value associated with the insurer issued label. The insurer issued label and value are necessary to identify the specific policy. For example, the Group or Plan number.
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| name | Σ | 0..1 | string | Element IdCoverage.class.name Human readable description of the type and value DefinitionA short description for the class. Used to provide a meaningful description in correspondence to the patient. Note that FHIR strings SHALL NOT exceed 1MB in size
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| order | Σ | 0..0 | positiveInt | Element IdCoverage.order Relative order of the coverage DefinitionThe 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. Es git derzeit in DE keine Verwendung für dieses Attribut (Konsens Interop-Forum 12.6.2017) Für die Priorisierung der Versicherungsverhältnisse sollte statt dessen Account.coverage.priority verwendet werden, da die Priorisierung abhängig von Fall- und Abrechnungsart unterschiedlich sein kann. Falls es UseCases gibt, die dieses Attribut benötigen, bitte Info auf chat.fhir.org
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| network | Σ | 0..0 | string | Element IdCoverage.network Insurer network DefinitionDie Versicherungsleistungen sind an ein bestimmtes Netzwerk von Gesundheitsdienstleistern gebunden Used in referral for treatment and in claims processing. Es gibt derzeit in DE keine Verwendung für dieses Attribut (Konsens Interop-Forum 12.6.2017) Falls es UseCases gibt, die dieses Attribut benötigen, bitte Info auf chat.fhir.org
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| costToBeneficiary | 0..* | BackboneElement | Element IdCoverage.costToBeneficiary Patient payments for services/products Alternate namesCoPay, Deductible, Exceptions DefinitionA 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. Required by providers to manage financial transaction with the patient. For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.
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| type | Σ | 0..1 | CodeableConceptBinding | Element IdCoverage.costToBeneficiary.type Cost category DefinitionThe category of patient centric costs associated with treatment. Needed to identify the category associated with the amount for the patient. For example visit, specialist visits, emergency, inpatient care, etc. coverage-copay-type (extensible) Constraints
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| value[x] | Σ | 1..1 | Element IdCoverage.costToBeneficiary.value[x] The amount or percentage due from the beneficiary DefinitionThe amount due from the patient for the cost category. Needed to identify the amount for the patient associated with the category. Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.
| |
| valueQuantity | SimpleQuantity | Data Type | ||
| valueMoney | Money | Data Type | ||
| exception | 0..* | BackboneElement | Element IdCoverage.costToBeneficiary.exception Exceptions for patient payments DefinitionA suite of codes indicating exceptions or reductions to patient costs and their effective periods. Required by providers to manage financial transaction with the patient.
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| type | Σ | 1..1 | CodeableConcept | Element IdCoverage.costToBeneficiary.exception.type Exception category DefinitionThe code for the specific exception. Needed to identify the exception associated with the amount for the patient. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. coverage-financial-exception (example) Constraints
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| period | Σ | 0..1 | Period | Element IdCoverage.costToBeneficiary.exception.period The effective period of the exception DefinitionThe timeframe during when the exception is in force. Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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| subrogation | 0..1 | boolean | Element IdCoverage.subrogation Reimbursement to insurer DefinitionWhen 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs. See definition for when to be used. Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.
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| contract | 0..* | Reference(Contract) | Element IdCoverage.contract Contract details DefinitionThe policy(s) which constitute this insurance coverage. To reference the legally binding contract between the policy holder and the insurer. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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Folgendes Beispiel deckt das GKV-Profil vollständig ab:
<Coverage xmlns="http://hl7.org/fhir"> <meta> <profile value="http://fhir.de/StructureDefinition/coverage-de-gkv" /> </meta> <extension url="http://fhir.de/StructureDefinition/gkv/einlesedatum-karte"> <valueDateTime value="2019-12-03" /> </extension> <extension url="http://fhir.de/StructureDefinition/gkv/version-egk"> <valueString value="5.2.1" /> </extension> <extension url="http://fhir.de/StructureDefinition/gkv/generation-egk"> <valueString value="1+" /> </extension> <extension url="http://fhir.de/StructureDefinition/gkv/versichertenart"> <valueCoding> <system value="https://fhir.kbv.de/CodeSystem/74_CS_SFHIR_KBV_VERSICHERTENSTATUS" /> <code value="1" /> </valueCoding> </extension> <extension url="http://fhir.de/StructureDefinition/gkv/kostenerstattung"> <extension url="aerztlicheVersorgung"> <valueBoolean value="true" /> </extension> <extension url="zahnaerztlicheVersorgung"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://fhir.de/StructureDefinition/gkv/wop"> <valueCoding> <system value="https://fhir.kbv.de/CodeSystem/CS_AW_Krankenversicherung_WOP" /> <code value="38" /> <display value="Nordrhein" /> </valueCoding> </extension> <extension url="http://fhir.de/StructureDefinition/gkv/besondere-personengruppe"> <valueCoding> <system value="https://fhir.kbv.de/CodeSystem/74_CS_SFHIR_KBV_PERSONENGRUPPE" /> <code value="06" /> <display value="BVG (Gesetz über die Versorgung der Opfer des Krieges)" /> </valueCoding> </extension> <extension url="http://fhir.de/StructureDefinition/gkv/ruhender-leistungsanspruch"> <extension url="art"> <valueCoding> <code value="1" /> </valueCoding> </extension> <extension url="dauer"> <valuePeriod> <start value="2018-01-01" /> </valuePeriod> </extension> </extension> <extension url="http://fhir.de/StructureDefinition/gkv/zuzahlungsstatus"> <extension url="status"> <valueBoolean value="true" /> </extension> <extension url="gueltigBis"> <valueDate value="2020-12-31" /> </extension> </extension> <identifier> <system value="http://fhir.de/NamingSystem/gkv/kvid-10" /> <value value="123454321" /> </identifier> <status value="active" /> <type> <coding> <system value="http://fhir.de/CodeSystem/versicherungsart-de-basis" /> <code value="GKV" /> </coding> </type> <subscriber> <reference value="Patient/example" /> <display value="Max Mustermann" /> </subscriber> <beneficiary> <reference value="Patient/example" /> <display value="Max Mustermann" /> </beneficiary> <payor> <identifier> <system value="http://fhir.de/NamingSystem/arge-ik/iknr" /> <value value="823746876" /> </identifier> <display value="Krankenkasse A" /> </payor> <payor> <identifier> <system value="http://fhir.de/NamingSystem/arge-ik/iknr" /> <value value="756756324" /> </identifier> <display value="Krankenkasse A, Zweigstelle B" /> </payor> </Coverage>
Für die Abbildung eines Selbstzahler-Verhältnisses sind über das Basisprofil hinaus folgende Mindestangaben erforderlich:
| Coverage | 0..* | Coverage | Element IdCoverage Versicherungsdaten DefinitionAngaben zur Versicherung oder zur Kostenübernahme durch den Patienten selbst oder durch Dritte. The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.
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| identifier | Σ | 0..* | Identifier | Element IdCoverage.identifier Business Identifier for the coverage DefinitionA unique identifier assigned to this coverage. Allows coverages to be distinguished and referenced. 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.
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| status | Σ ?! | 1..1 | codeBinding | Element IdCoverage.status active | cancelled | draft | entered-in-error DefinitionThe status of the resource instance. 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 labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.
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| type | Σ | 1..1 | CodeableConceptBinding | Element IdCoverage.type Versicherungsart DefinitionArt der Versicherung: Selbstzahler, gesetzliche/private Versicherung, Berufsgenossenschaft oder Sozialamt The order of application of coverages is dependent on the types of coverage. 28.07.2017 (zulip): TC Konsens bzgl. Verwendung eines eigenen ValueSets anstelle des im Standrad definierten preferred bindings, da die dort igen Codes nicht passen. VersicherungsartDeBasis (required) Constraints
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| coding | Σ | 1..* | Coding | Element IdCoverage.type.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| system | Σ | 1..1 | uriFixed Value | Element IdCoverage.type.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://fhir.de/CodeSystem/versicherungsart-de-basis
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| version | Σ | 0..1 | string | Element IdCoverage.type.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | codeFixed Value | Element IdCoverage.type.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
SEL
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| display | Σ | 0..1 | string | Element IdCoverage.type.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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| userSelected | Σ | 0..1 | boolean | Element IdCoverage.type.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | Element IdCoverage.type.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| policyHolder | Σ | 0..0 | Reference(Patient| RelatedPerson| Organization) | Element IdCoverage.policyHolder Owner of the policy DefinitionThe party who 'owns' the insurance policy. This provides employer information in the case of Worker's Compensation and other policies. Es gibt derzeit in DE keine Verwendung für dieses Attribut (Konsens Interop-Forum 12.6.2017) Falls es UseCases gibt, die dieses Attribut benötigen, bitte Info auf chat.fhir.org Reference(Patient| RelatedPerson| Organization) Constraints
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| subscriber | Σ | 0..1 | Reference(Patient| RelatedPerson) | Element IdCoverage.subscriber Unterzeichner der Kostenübernahme DefinitionPerson, die dies Kostenübernahme zusichert (entweder der Patient selbst oder eine andere Person, z.B. ein Elternteil) This is the party who is entitled to the benfits under the policy. May be self or a parent in the case of dependants. Reference(Patient| RelatedPerson) Constraints
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| subscriberId | Σ | 0..0 | string | Element IdCoverage.subscriberId ID assigned to the subscriber DefinitionThe insurer assigned ID for the Subscriber. The insurer requires this identifier on correspondance and claims (digital and otherwise). Note that FHIR strings SHALL NOT exceed 1MB in size
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| beneficiary | Σ | 1..1 | Reference(Patient) | Element IdCoverage.beneficiary Begünstigte Person DefinitionPerson, auf die sich die Kostenübernahme bezieht (der Patient) This is the party who receives treatment for which the costs are reimbursed under the coverage. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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| dependent | Σ | 0..1 | string | Element IdCoverage.dependent Dependent number DefinitionA unique identifier for a dependent under the coverage. For some coverages a single identifier is issued to the Subscriber and then a unique dependent number is issued to each beneficiary. Periodically the member number is constructed from the subscriberId and the dependant number.
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| relationship | 0..1 | CodeableConceptBinding | Element IdCoverage.relationship Beneficiary relationship to the subscriber DefinitionThe relationship of beneficiary (patient) to the subscriber. To determine relationship between the patient and the subscriber to determine coordination of benefits. Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others. subscriber-relationship (extensible) Constraints
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| period | Σ | 0..1 | Period | Element IdCoverage.period Coverage start and end dates DefinitionTime 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. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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| payor | Σ | 1..* | Reference(Organization| RelatedPerson| Patient) | Element IdCoverage.payor Kostenübernehmer DefinitionPerson, die die Kosten übernimmt (beim Selbstzahlerverhältnis i.d.R. identisch mit subscriber) Sonderfall: Die Kostenübernahme wird von einer Person (subscriber) erklärt, die Übernahme erfolgt jedoch durch eine Organisation Need to identify the issuer to target for claim processing and for coordination of benefit processing. 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. Reference(Organization| RelatedPerson| Patient) Constraints
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| class | 0..* | BackboneElement | Element IdCoverage.class Additional coverage classifications DefinitionA suite of underwriter specific classifiers. The codes provided on the health card which identify or confirm the specific policy for the insurer. For example may be used to identify a class of coverage or employer group, Policy, Plan.
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| type | Σ | 1..1 | CodeableConceptBinding | Element IdCoverage.class.type Type of class such as 'group' or 'plan' DefinitionThe 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| value | Σ | 1..1 | string | Element IdCoverage.class.value Value associated with the type DefinitionThe alphanumeric string value associated with the insurer issued label. The insurer issued label and value are necessary to identify the specific policy. For example, the Group or Plan number.
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| name | Σ | 0..1 | string | Element IdCoverage.class.name Human readable description of the type and value DefinitionA short description for the class. Used to provide a meaningful description in correspondence to the patient. Note that FHIR strings SHALL NOT exceed 1MB in size
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| order | Σ | 0..0 | positiveInt | Element IdCoverage.order Relative order of the coverage DefinitionThe 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. Es git derzeit in DE keine Verwendung für dieses Attribut (Konsens Interop-Forum 12.6.2017) Für die Priorisierung der Versicherungsverhältnisse sollte statt dessen Account.coverage.priority verwendet werden, da die Priorisierung abhängig von Fall- und Abrechnungsart unterschiedlich sein kann. Falls es UseCases gibt, die dieses Attribut benötigen, bitte Info auf chat.fhir.org
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| network | Σ | 0..0 | string | Element IdCoverage.network Insurer network DefinitionDie Versicherungsleistungen sind an ein bestimmtes Netzwerk von Gesundheitsdienstleistern gebunden Used in referral for treatment and in claims processing. Es gibt derzeit in DE keine Verwendung für dieses Attribut (Konsens Interop-Forum 12.6.2017) Falls es UseCases gibt, die dieses Attribut benötigen, bitte Info auf chat.fhir.org
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| costToBeneficiary | 0..* | BackboneElement | Element IdCoverage.costToBeneficiary Patient payments for services/products Alternate namesCoPay, Deductible, Exceptions DefinitionA 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. Required by providers to manage financial transaction with the patient. For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.
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| type | Σ | 0..1 | CodeableConceptBinding | Element IdCoverage.costToBeneficiary.type Cost category DefinitionThe category of patient centric costs associated with treatment. Needed to identify the category associated with the amount for the patient. For example visit, specialist visits, emergency, inpatient care, etc. coverage-copay-type (extensible) Constraints
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| value[x] | Σ | 1..1 | Element IdCoverage.costToBeneficiary.value[x] The amount or percentage due from the beneficiary DefinitionThe amount due from the patient for the cost category. Needed to identify the amount for the patient associated with the category. Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.
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| valueQuantity | SimpleQuantity | Data Type | ||
| valueMoney | Money | Data Type | ||
| exception | 0..* | BackboneElement | Element IdCoverage.costToBeneficiary.exception Exceptions for patient payments DefinitionA suite of codes indicating exceptions or reductions to patient costs and their effective periods. Required by providers to manage financial transaction with the patient.
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| type | Σ | 1..1 | CodeableConcept | Element IdCoverage.costToBeneficiary.exception.type Exception category DefinitionThe code for the specific exception. Needed to identify the exception associated with the amount for the patient. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. coverage-financial-exception (example) Constraints
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| period | Σ | 0..1 | Period | Element IdCoverage.costToBeneficiary.exception.period The effective period of the exception DefinitionThe timeframe during when the exception is in force. Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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| subrogation | 0..1 | boolean | Element IdCoverage.subrogation Reimbursement to insurer DefinitionWhen 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs. See definition for when to be used. Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.
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| contract | 0..* | Reference(Contract) | Element IdCoverage.contract Contract details DefinitionThe policy(s) which constitute this insurance coverage. To reference the legally binding contract between the policy holder and the insurer. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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