FHIR Implementation Guide for NJSAMS
0.1.0 - draft
New Jersey
0.1.0 - draft
New Jersey
NJSAMS - Local Development build (v0.1.0). See the Directory of published versions
| Official URL: http://dhs.nj.gov/njsams/StructureDefinition/NJSAMSCoverage | Version: 0.1.0 | |||
| Active as of 2022-09-13 | Computable Name: NJSAMSCoverage | |||
NJSAMS Coverage
The NJSAMS Coverage profile is used to associate a client and the payor program financing their treatement.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Coverage
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
  Slices for identifier | S | 0..* | Identifier | Business Identifier for the coverage Slice: Unordered, Open by value:system |
   identifier:sbi | 0..1 | Identifier | SBI Number | |
   system | 1..1 | uri | The namespace for the identifier value Required Pattern: http://dhs.nj.gov/njsams/sbi | |
 value | 0..1 | string | The value that is unique | |
 status | 1..1 | code | active | cancelled | draft | entered-in-error | |
| beneficiary | 1..1 | Reference(Patient) | Plan beneficiary | |
 payor | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |||||
 id | Σ | 0..1 | id | Logical id of this artifact | ||||
 meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| 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.
| |||||
| 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 | SΣ | 0..* | Identifier | Business Identifier for the coverage Slice: Unordered, Open by value:system | ||||
| identifier:sbi | Σ | 0..1 | Identifier | SBI Number | ||||
| 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. | ||||
| system | Σ | 1..1 | uri | The namespace for the identifier value Required Pattern: http://dhs.nj.gov/njsams/sbi | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
 assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| type | Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. | ||||
| policyHolder | Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | ||||
| subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | ||||
| subscriberId | Σ | 0..1 | string | ID assigned to the subscriber | ||||
| beneficiary | Σ | 1..1 | Reference(Patient) | Plan beneficiary | ||||
| dependent | Σ | 0..1 | string | Dependent number | ||||
| relationship | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). | |||||
| period | Σ | 0..1 | Period | Coverage start and end dates | ||||
| payor | Σ | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy | ||||
| class | 0..* | BackboneElement | Additional coverage classifications | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. | ||||
| value | Σ | 1..1 | string | Value associated with the type | ||||
| name | Σ | 0..1 | string | Human readable description of the type and value | ||||
| order | Σ | 0..1 | positiveInt | Relative order of the coverage | ||||
| network | Σ | 0..1 | string | Insurer network | ||||
| costToBeneficiary | 0..* | BackboneElement | Patient payments for services/products | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified. | ||||
 value[x] | Σ | 1..1 | The amount or percentage due from the beneficiary | |||||
| valueQuantity | Quantity(SimpleQuantity) | |||||||
| valueMoney | Money | |||||||
 exception | 0..* | BackboneElement | Exceptions for patient payments | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | Σ | 1..1 | CodeableConcept | Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays. | ||||
| period | Σ | 0..1 | Period | The effective period of the exception | ||||
| subrogation | 0..1 | boolean | Reimbursement to insurer | |||||
| contract | 0..* | Reference(Contract) | Contract details | |||||
| Documentation for this format | ||||||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
| identifier | Σ | 0..* | Identifier | Business Identifier for the coverage Slice: Unordered, Open by value:system |
| Documentation for this format | ||||
This structure is derived from Coverage
Summary
Mandatory: 0 element (1 nested mandatory element)
Must-Support: 1 element
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Coverage
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
| Slices for identifier | S | 0..* | Identifier | Business Identifier for the coverage Slice: Unordered, Open by value:system |
| identifier:sbi | 0..1 | Identifier | SBI Number | |
| system | 1..1 | uri | The namespace for the identifier value Required Pattern: http://dhs.nj.gov/njsams/sbi | |
| value | 0..1 | string | The value that is unique | |
| status | 1..1 | code | active | cancelled | draft | entered-in-error | |
| beneficiary | 1..1 | Reference(Patient) | Plan beneficiary | |
| payor | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| 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.
| |||||
| 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 | SΣ | 0..* | Identifier | Business Identifier for the coverage Slice: Unordered, Open by value:system | ||||
| identifier:sbi | Σ | 0..1 | Identifier | SBI Number | ||||
| 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. | ||||
| system | Σ | 1..1 | uri | The namespace for the identifier value Required Pattern: http://dhs.nj.gov/njsams/sbi | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| type | Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. | ||||
| policyHolder | Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | ||||
| subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | ||||
| subscriberId | Σ | 0..1 | string | ID assigned to the subscriber | ||||
| beneficiary | Σ | 1..1 | Reference(Patient) | Plan beneficiary | ||||
| dependent | Σ | 0..1 | string | Dependent number | ||||
| relationship | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). | |||||
| period | Σ | 0..1 | Period | Coverage start and end dates | ||||
| payor | Σ | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy | ||||
| class | 0..* | BackboneElement | Additional coverage classifications | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. | ||||
| value | Σ | 1..1 | string | Value associated with the type | ||||
| name | Σ | 0..1 | string | Human readable description of the type and value | ||||
| order | Σ | 0..1 | positiveInt | Relative order of the coverage | ||||
| network | Σ | 0..1 | string | Insurer network | ||||
| costToBeneficiary | 0..* | BackboneElement | Patient payments for services/products | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified. | ||||
| value[x] | Σ | 1..1 | The amount or percentage due from the beneficiary | |||||
| valueQuantity | Quantity(SimpleQuantity) | |||||||
| valueMoney | Money | |||||||
| exception | 0..* | BackboneElement | Exceptions for patient payments | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | Σ | 1..1 | CodeableConcept | Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays. | ||||
| period | Σ | 0..1 | Period | The effective period of the exception | ||||
| subrogation | 0..1 | boolean | Reimbursement to insurer | |||||
| contract | 0..* | Reference(Contract) | Contract details | |||||
| Documentation for this format | ||||||||
Other representations of profile: CSV, Excel, Schematron
| Path | Conformance | ValueSet |
| Coverage.language | preferred | CommonLanguages Max Binding: AllLanguages |
| Coverage.identifier:sbi.use | required | IdentifierUse |
| Coverage.identifier:sbi.type | extensible | Identifier Type Codes |
| Coverage.status | required | FinancialResourceStatusCodes |
| Coverage.type | preferred | CoverageTypeAndSelf-PayCodes |
| Coverage.relationship | extensible | SubscriberRelationshipCodes |
| Coverage.class.type | extensible | CoverageClassCodes |
| Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes |
| Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes |
| Id | Grade | Path | Details | Requirements |
| dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Coverage | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | Best Practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | Coverage.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Coverage.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Coverage.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Coverage.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Coverage.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.identifier:sbi | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.identifier:sbi.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Coverage.identifier:sbi.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Coverage.identifier:sbi.use | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.identifier:sbi.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.identifier:sbi.system | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.identifier:sbi.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.identifier:sbi.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.identifier:sbi.assigner | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.policyHolder | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.subscriber | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.subscriberId | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.beneficiary | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.dependent | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.relationship | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.payor | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.class | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.class.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Coverage.class.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Coverage.class.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Coverage.class.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Coverage.class.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.class.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.class.name | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.order | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.network | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.costToBeneficiary | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.costToBeneficiary.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Coverage.costToBeneficiary.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Coverage.costToBeneficiary.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Coverage.costToBeneficiary.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Coverage.costToBeneficiary.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.costToBeneficiary.value[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.costToBeneficiary.exception | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.costToBeneficiary.exception.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Coverage.costToBeneficiary.exception.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Coverage.costToBeneficiary.exception.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Coverage.costToBeneficiary.exception.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Coverage.costToBeneficiary.exception.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.costToBeneficiary.exception.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.subrogation | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Coverage.contract | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |