Coverage.shex

ShEx statement for coverage

PREFIX fhir: <http://hl7.org/fhir/> 
PREFIX fhirvs: <http://hl7.org/fhir/ValueSet/>
PREFIX xsd: <http://www.w3.org/2001/XMLSchema#> 
PREFIX rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> 
IMPORT <code.shex>
IMPORT <Money.shex>
IMPORT <string.shex>
IMPORT <Period.shex>
IMPORT <Patient.shex>
IMPORT <boolean.shex>
IMPORT <Contract.shex>
IMPORT <Reference.shex>
IMPORT <Identifier.shex>
IMPORT <positiveInt.shex>
IMPORT <Organization.shex>
IMPORT <RelatedPerson.shex>
IMPORT <InsurancePlan.shex>
IMPORT <DomainResource.shex>
IMPORT <SimpleQuantity.shex>
IMPORT <CodeableConcept.shex>
IMPORT <BackboneElement.shex>
start=@<Coverage> AND {fhir:nodeRole [fhir:treeRoot]}
# Insurance or medical plan or a payment agreement
<Coverage> EXTENDS @<DomainResource> CLOSED { 
 a [fhir:Coverage]?;
 fhir:nodeRole [fhir:treeRoot]?;
 fhir:identifier @<OneOrMore_Identifier>?; # Business identifier(s) for this 
 # coverage 
 fhir:status @<code> AND
 	{fhir:v @fhirvs:fm-status}; # active | cancelled | draft | 
 # entered-in-error 
 fhir:kind @<code> AND
 	{fhir:v @fhirvs:coverage-kind}; # insurance | self-pay | other
 fhir:paymentBy @<OneOrMore_Coverage.paymentBy>?; # Self-pay parties and responsibility
 fhir:type @<CodeableConcept>?; # Coverage category such as medical 
 # or accident 
 fhir:policyHolder @<Reference> AND {fhir:link 
 			@<Organization> OR 
 			@<Patient> OR 
 			@<RelatedPerson> ? }?; # Owner of the policy
 fhir:subscriber @<Reference> AND {fhir:link 
 			@<Patient> OR 
 			@<RelatedPerson> ? }?; # Subscriber to the policy
 fhir:subscriberId @<OneOrMore_Identifier>?; # ID assigned to the subscriber
 fhir:beneficiary @<Reference> AND {fhir:link 
 			@<Patient> ? }; # Plan beneficiary
 fhir:dependent @<string>?; # Dependent number
 fhir:relationship @<CodeableConcept>?; # Beneficiary relationship to the 
 # subscriber 
 fhir:period @<Period>?; # Coverage start and end dates
 fhir:insurer @<Reference> AND {fhir:link 
 			@<Organization> ? }?; # Issuer of the policy
 fhir:class @<OneOrMore_Coverage.class>?; # Additional coverage classifications
 fhir:order @<positiveInt>?; # Relative order of the coverage
 fhir:network @<string>?; # Insurer network
 fhir:costToBeneficiary @<OneOrMore_Coverage.costToBeneficiary>?; # Patient payments for 
 # services/products 
 fhir:subrogation @<boolean>?; # Reimbursement to insurer
 fhir:contract @<OneOrMore_Reference_Contract>?; # Contract details
 fhir:insurancePlan @<Reference> AND {fhir:link 
 			@<InsurancePlan> ? }?; # Insurance plan details
} 
# Exceptions for patient payments
<Coverage.costToBeneficiary.exception> EXTENDS @<BackboneElement> CLOSED { 
 fhir:type @<CodeableConcept>; # Exception category
 fhir:period @<Period>?; # The effective period of the 
 # exception 
} 
# Self-pay parties and responsibility
<Coverage.paymentBy> EXTENDS @<BackboneElement> CLOSED { 
 fhir:party @<Reference> AND {fhir:link 
 			@<Organization> OR 
 			@<Patient> OR 
 			@<RelatedPerson> ? }; # Parties performing self-payment
 fhir:responsibility @<string>?; # Party's responsibility
} 
# Patient payments for services/products
<Coverage.costToBeneficiary> EXTENDS @<BackboneElement> CLOSED { 
 fhir:type @<CodeableConcept>?; # Cost category
 fhir:category @<CodeableConcept>?; # Benefit classification
 fhir:network @<CodeableConcept>?; # In or out of network
 fhir:unit @<CodeableConcept>?; # Individual or family
 fhir:term @<CodeableConcept>?; # Annual or lifetime
 fhir:value @<SimpleQuantity> OR 
 			@<Money> ?; # The amount or percentage due from 
 # the beneficiary 
 fhir:exception @<OneOrMore_Coverage.costToBeneficiary.exception>?; # Exceptions for patient payments
} 
# Additional coverage classifications
<Coverage.class> EXTENDS @<BackboneElement> CLOSED { 
 fhir:type @<CodeableConcept>; # Type of class such as 'group' or 
 # 'plan' 
 fhir:value @<Identifier>; # Value associated with the type
 fhir:name @<string>?; # Human readable description of the 
 # type and value 
} 
#---------------------- Cardinality Types (OneOrMore) -------------------
<OneOrMore_Identifier> CLOSED {
 rdf:first @<Identifier> ;
 rdf:rest [rdf:nil] OR @<OneOrMore_Identifier> 
}
<OneOrMore_Coverage.paymentBy> CLOSED {
 rdf:first @<Coverage.paymentBy> ;
 rdf:rest [rdf:nil] OR @<OneOrMore_Coverage.paymentBy> 
}
<OneOrMore_Coverage.class> CLOSED {
 rdf:first @<Coverage.class> ;
 rdf:rest [rdf:nil] OR @<OneOrMore_Coverage.class> 
}
<OneOrMore_Coverage.costToBeneficiary> CLOSED {
 rdf:first @<Coverage.costToBeneficiary> ;
 rdf:rest [rdf:nil] OR @<OneOrMore_Coverage.costToBeneficiary> 
}
<OneOrMore_Reference_Contract> CLOSED {
 rdf:first @<Reference> AND {fhir:link 
			@<Contract> } ;
 rdf:rest [rdf:nil] OR @<OneOrMore_Reference_Contract> 
}
<OneOrMore_Coverage.costToBeneficiary.exception> CLOSED {
 rdf:first @<Coverage.costToBeneficiary.exception> ;
 rdf:rest [rdf:nil] OR @<OneOrMore_Coverage.costToBeneficiary.exception> 
}
#---------------------- Value Sets ------------------------
# The kind of coverage: insurance, selfpay or other.
fhirvs:coverage-kind ["insurance" "self-pay" "other"]
# This value set includes Status codes.
fhirvs:fm-status ["active" "cancelled" "draft" "entered-in-error"]