HL7 FHIR JP Core ImplementationGuide
1.1.0 - release
HL7 FHIR JP Core ImplementationGuide
1.1.0 - release
HL7 FHIR JP Core ImplementationGuide - Local Development build (v1.1.0). See the Directory of published versions
| 項目 | 内容 |
| 定義URL | http://jpfhir.jp/fhir/core/StructureDefinition/JP_Coverage |
| Version | 1.1.0 |
| Name | JP_Coverage |
| Title | JP Core Coverage Profile |
| Status | Active ( 2022-10-24 ) |
| Copyright | Copyright FHIR Japanese implementation research working group in Japan Association of Medical Informatics (JAMI) 一般社団法人日本医療情報学会NeXEHRS課題研究会FHIR日本実装検討WG |
このプロファイルはCoverageリソースに対して、保険・公費のデータを送受信するための基礎となる制約と拡張を定めたものである。
本プロファイルは、以下のようなユースケースを想定している。
Coverageリソースは、医療・介護保険における識別子・記述子を提供することを想定しており、典型的には保険証に記載される情報であり、医療や介護サービスの提供に対する対価として、一部または全ての支払いに使用される可能性がある。
このリソースは、保険者以外の個人または組織が医療費の一部の支払いに責任を持つ「自己負担」を登録するためにも使用できる。ここで定義する「自己負担」は、患者の支払いの保証人になることとは別のものであることに留意する。
Coverage リソースは、FHIRワークフローの観点からは「イベント」に該当するリソースである。詳細はWorkflowの項目を参照のこと。
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
  Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement 保険または医療費支払いプラン、または合意された支払い方法 | |||||
  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 | |||||
 Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
 insuredPersonSymbol | 0..* | string | 健康保険における被保険者証記号 URL: http://jpfhir.jp/fhir/core/Extension/StructureDefinition/JP_Coverage_InsuredPersonSymbol | |||||
| insuredPersonNumber | 0..* | string | 健康保険における被保険者証番号 URL: http://jpfhir.jp/fhir/core/Extension/StructureDefinition/JP_Coverage_InsuredPersonNumber | |||||
| insuredPersonSubNumber | 0..* | string | 健康保険における被保険者証番号の枝番 URL: http://jpfhir.jp/fhir/core/Extension/StructureDefinition/JP_Coverage_InsuredPersonSubNumber | |||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..* | Identifier | Business Identifier for the coverage このカバレッジに割り当てられた一意の識別子。【詳細参照】 | ||||
| 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 医療保険や事故補償のような分類 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(JP Core Patient Profile | RelatedPerson | JP Core Organization Profile) | Owner of the policy ポリシの所有者 | ||||
| subscriber | Σ | 0..1 | Reference(JP Core Patient Profile | RelatedPerson) | Subscriber to the policy 被保険者 | ||||
| subscriberId | Σ | 0..1 | string | ID assigned to the subscriber 被保険者に割り当てられたID | ||||
| beneficiary | Σ | 1..1 | Reference(JP Core Patient Profile) | Plan beneficiary | ||||
| dependent | Σ | 0..1 | string | 被保険者証 枝番 | ||||
| relationship | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber 加入者との受益者関係 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(JP Core Organization Profile | JP Core Patient Profile | 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 サービスやプロダクトに対する患者支払い | |||||
| 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. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 0..1 | uri | Identity of the terminology system | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display | Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
 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 保険者への償還 | |||||
| contract | 0..* | Reference(Contract) | Contract details 契約の詳細 | |||||
| Documentation for this format | ||||||||
Other representations of profile: CSV, Excel, Schematron
Coverage リソースは、次の要素を必ず持たなければならない。
JP Core Coverage プロファイルで使用される拡張は次の通りである。
| コンフォーマンス | パラメータ | 型 | 例 |
|---|---|---|---|
| SHALL | identifier | token | GET [base]/Coverage?identifier=*** |
| SHOULD | beneficiary | reference | GET [base]/Coverage?beneficiary=*** |
| SHOULD | class-type | token | GET [base]/Coverage.class?type=*** |
| SHOULD | class-value | string | GET [base]/Coverage.class?value=*** |
| SHOULD | dependent | string | GET [base]/Coverage?dependent=*** |
| SHOULD | patient | reference | GET [base]/Coverage?beneficiary=Patient/*** |
| SHOULD | payor | reference | GET [base]/Coverage?payor=*** |
| SHOULD | policy-holder | reference | GET [base]/Coverage?policy-holder=*** |
| SHOULD | status | token | GET [base]/Coverage?status=*** |
| SHOULD | subscriber | reference | GET [base]/Coverage?subscriber=*** |
| SHOULD | type | token | GET [base]/Coverage?token=*** |
次の検索パラメータをサポートすることが望ましい。
beneficiary 検索パラメータを使用して、識別子によるCoverageの検索をサポートすることが望ましい（SHOULD）
GET [base]/Coverage?beneficiary={system|}[code]
例：
GET [base]/Coverage?beneficiary=*****
指定された識別子に一致するCoverageリソースを含むBundleを検索する。
class-type 検索パラメータを使用して、言語コードによるOrganizationの検索をサポートすることが望ましい（SHOULD）
GET [base]/Coverage.class?type={token}
例：
GET [base]/Coverageclass?type=*****