Blue Button 2.0 Implementation Guide

SD.3 StructureDefinition-bluebutton-coverage

This profile sets minimum expectations for the [Coverage] Coverage resource to record, search and fetch basic demographics and other administrative information about an individual Coverage. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile.

Example Usage Scenarios:

The following are example usage scenarios for the Blue Button Coverage profile:

Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present). These are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Coverage must have:

  1. an id
  2. a status
  3. a type
  4. a beneficiary
  5. a grouping

If the data is available a Coverage shall include:

  1. The following Coverage level extensions: - coverage-ms-cd-extension - coverage-orec-extension - coverage-crec-extension - coverage-esrd-ind-extension - coverage-a-trm-cd-extension - coverage-b-trm-cd-extension

Profile specific implementation guidance:

  • none

Examples

  • none

SD.3.1 Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage.html

Published on Tue Nov 20 16:11:24 UTC 2018 as a draft by CMS Blue Button 2.0 Team.

This profile builds on Coverage

Complete Summary of the Mandatory Requirements

  1. An id in Coverage.id

  2. One status in Coverage.status

  3. One type in Coverage.type
    • a Coverage.type must have:
      • a type.coding, and each coding must have: - a coding.system - a coding.code
  4. One patient in Coverage.beneficiary
    • a Coverage.beneficiary must have:
      • a beneficiary.reference
  5. One or more item in Coverage.grouping
    • a Coverage.grouping must have:
      • a grouping.subGroup
      • a grouping.subPlan

Summary of the Must Support Requirements

Additionally your system must support:

  1. The following Coverage extensions: - Coverage.coverage-ms-cd-extension - Coverage.coverage-orec-extension - Coverage.coverage-crec-extension - Coverage.coverage-esrd-ind-extension - Coverage.coverage-a-trm-cd-extension - Coverage.coverage-b-trm-cd-extension
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*Coverage resource
... id 1..
... meta ..0
... implicitRules ..0
... language ..0
... text ..0
... contained ..0
... identifier ..0
... status 1..
... type 1..
.... coding 1..1
..... system 1..
..... version ..0
..... code 1..
..... display ..0
..... userSelected ..0
.... text ..0
... policyHolder ..0
... subscriber ..0
... subscriberId ..0
... beneficiary 1..
.... reference 1..
.... identifier ..0
.... display ..0
... relationship ..0
... period ..0
... payor ..0
... grouping 1..
.... id ..0
.... group ..0
.... groupDisplay ..0
.... subGroup 1..
.... subGroupDisplay ..0
.... plan ..0
.... planDisplay ..0
.... subPlan 1..
.... subPlanDisplay ..0
.... class ..0
.... classDisplay ..0
.... subClass ..0
.... subClassDisplay ..0
... dependent ..0
... sequence ..0
... order ..0
... network ..0
... contract ..0
... bluebutton-coverage-a-trm-cd-extension ..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-a-trm-cd-extension
Binding: Part A Termination Code (required)
... bluebutton-coverage-b-trm-cd-extension ..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-b-trm-cd-extension
Binding: Part B Termination Code (required)
... bluebutton-coverage-crec-extension ..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-crec-extension
Binding: Current Reason for Entitlement Code (required)
... bluebutton-coverage-esrd-ind-extension ..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-esrd-ind-extension
Binding: End-stage Renal Disease (ESRD) Indicator (required)
... bluebutton-coverage-ms-cd-extension ..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-ms-cd-extension
Binding: https://bluebutton.cms.gov/assets/ig/ValueSet-ms-cd (required)
... bluebutton-coverage-orec-extension ..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-orec-extension
Binding: Original Reason for Entitlement Code (required)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*Insurance or medical plan or a payment agreement
... id Σ1..1idLogical id of this artifact
... bluebutton-coverage-a-trm-cd-extension 0..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-a-trm-cd-extension
Binding: Part A Termination Code (required)
... bluebutton-coverage-b-trm-cd-extension 0..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-b-trm-cd-extension
Binding: Part B Termination Code (required)
... bluebutton-coverage-crec-extension 0..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-crec-extension
Binding: Current Reason for Entitlement Code (required)
... bluebutton-coverage-esrd-ind-extension 0..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-esrd-ind-extension
Binding: End-stage Renal Disease (ESRD) Indicator (required)
... bluebutton-coverage-ms-cd-extension 0..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-ms-cd-extension
Binding: https://bluebutton.cms.gov/assets/ig/ValueSet-ms-cd (required)
... bluebutton-coverage-orec-extension 0..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-orec-extension
Binding: Original Reason for Entitlement Code (required)
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes (required)
... type Σ1..1CodeableConceptType of coverage such as medical or accident
Binding: Coverage Type and Self-Pay Codes (preferred)
.... id 0..1stringxml:id (or equivalent in JSON)
.... coding Σ1..1CodingCode defined by a terminology system
..... id 0..1stringxml:id (or equivalent in JSON)
..... system Σ1..1uriIdentity of the terminology system
..... code Σ1..1codeSymbol in syntax defined by the system
... beneficiary ΣI1..1Reference(Patient)Plan Beneficiary
ref-1: SHALL have a contained resource if a local reference is provided
.... id 0..1stringxml:id (or equivalent in JSON)
.... reference Σ1..1stringLiteral reference, Relative, internal or absolute URL
... grouping 1..1BackboneElementAdditional coverage classifications
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... subGroup Σ1..1stringAn identifier for the subsection of the group
.... subPlan Σ1..1stringAn identifier for the subsection of the plan

doco Documentation for this format

Complete Summary of the Mandatory Requirements

  1. An id in Coverage.id

  2. One status in Coverage.status

  3. One type in Coverage.type
    • a Coverage.type must have:
      • a type.coding, and each coding must have: - a coding.system - a coding.code
  4. One patient in Coverage.beneficiary
    • a Coverage.beneficiary must have:
      • a beneficiary.reference
  5. One or more item in Coverage.grouping
    • a Coverage.grouping must have:
      • a grouping.subGroup
      • a grouping.subPlan

Summary of the Must Support Requirements

Additionally your system must support:

  1. The following Coverage extensions: - Coverage.coverage-ms-cd-extension - Coverage.coverage-orec-extension - Coverage.coverage-crec-extension - Coverage.coverage-esrd-ind-extension - Coverage.coverage-a-trm-cd-extension - Coverage.coverage-b-trm-cd-extension

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*Coverage resource
... id 1..
... meta ..0
... implicitRules ..0
... language ..0
... text ..0
... contained ..0
... identifier ..0
... status 1..
... type 1..
.... coding 1..1
..... system 1..
..... version ..0
..... code 1..
..... display ..0
..... userSelected ..0
.... text ..0
... policyHolder ..0
... subscriber ..0
... subscriberId ..0
... beneficiary 1..
.... reference 1..
.... identifier ..0
.... display ..0
... relationship ..0
... period ..0
... payor ..0
... grouping 1..
.... id ..0
.... group ..0
.... groupDisplay ..0
.... subGroup 1..
.... subGroupDisplay ..0
.... plan ..0
.... planDisplay ..0
.... subPlan 1..
.... subPlanDisplay ..0
.... class ..0
.... classDisplay ..0
.... subClass ..0
.... subClassDisplay ..0
... dependent ..0
... sequence ..0
... order ..0
... network ..0
... contract ..0
... bluebutton-coverage-a-trm-cd-extension ..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-a-trm-cd-extension
Binding: Part A Termination Code (required)
... bluebutton-coverage-b-trm-cd-extension ..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-b-trm-cd-extension
Binding: Part B Termination Code (required)
... bluebutton-coverage-crec-extension ..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-crec-extension
Binding: Current Reason for Entitlement Code (required)
... bluebutton-coverage-esrd-ind-extension ..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-esrd-ind-extension
Binding: End-stage Renal Disease (ESRD) Indicator (required)
... bluebutton-coverage-ms-cd-extension ..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-ms-cd-extension
Binding: https://bluebutton.cms.gov/assets/ig/ValueSet-ms-cd (required)
... bluebutton-coverage-orec-extension ..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-orec-extension
Binding: Original Reason for Entitlement Code (required)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*Insurance or medical plan or a payment agreement
... id Σ1..1idLogical id of this artifact
... bluebutton-coverage-a-trm-cd-extension 0..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-a-trm-cd-extension
Binding: Part A Termination Code (required)
... bluebutton-coverage-b-trm-cd-extension 0..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-b-trm-cd-extension
Binding: Part B Termination Code (required)
... bluebutton-coverage-crec-extension 0..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-crec-extension
Binding: Current Reason for Entitlement Code (required)
... bluebutton-coverage-esrd-ind-extension 0..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-esrd-ind-extension
Binding: End-stage Renal Disease (ESRD) Indicator (required)
... bluebutton-coverage-ms-cd-extension 0..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-ms-cd-extension
Binding: https://bluebutton.cms.gov/assets/ig/ValueSet-ms-cd (required)
... bluebutton-coverage-orec-extension 0..1CodingOptional Extensions Element
URL: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-coverage-orec-extension
Binding: Original Reason for Entitlement Code (required)
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes (required)
... type Σ1..1CodeableConceptType of coverage such as medical or accident
Binding: Coverage Type and Self-Pay Codes (preferred)
.... id 0..1stringxml:id (or equivalent in JSON)
.... coding Σ1..1CodingCode defined by a terminology system
..... id 0..1stringxml:id (or equivalent in JSON)
..... system Σ1..1uriIdentity of the terminology system
..... code Σ1..1codeSymbol in syntax defined by the system
... beneficiary ΣI1..1Reference(Patient)Plan Beneficiary
ref-1: SHALL have a contained resource if a local reference is provided
.... id 0..1stringxml:id (or equivalent in JSON)
.... reference Σ1..1stringLiteral reference, Relative, internal or absolute URL
... grouping 1..1BackboneElementAdditional coverage classifications
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... subGroup Σ1..1stringAn identifier for the subsection of the group
.... subPlan Σ1..1stringAn identifier for the subsection of the plan

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON, CSV), Schema: XML Schematron