HL7 FHIR JP Core ImplementationGuide
1.1.0 - release Japan flag

HL7 FHIR JP Core ImplementationGuide - Local Development build (v1.1.0). See the Directory of published versions

Resource Profile: JP Core Coverage Profile

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。


背景および想定シナリオ

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。

  • 病院の電子カルテシステムや医事システム、診療所や調剤薬局のシステム、介護サービスを提供する施設のシステム等において、サービス利用者（患者）の支払いに適用する保険や公費の種類、自己負担割合や自己負担上限額などを管理する
  • サービス利用者や保険者が実際に支払う負担額を管理する
  • サービス利用者や保険者を除く個人又は組織が支払いの全額又は一部に責任を持つ場合の負担額を管理する

スコープ


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。

プロファイル定義

Usage:

プロファイル詳細

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance 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
... Slices for extension 0..*ExtensionExtension
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
... identifier 0..*IdentifierBusiness 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 1..1codeactive | cancelled | draft | entered-in-error
... type 0..1CodeableConceptCoverage category such as medical or accident　医療保険や事故補償のような分類
... policyHolder 0..1Reference(JP Core Patient Profile | RelatedPerson | JP Core Organization Profile)Owner of the policy　ポリシの所有者
... subscriber 0..1Reference(JP Core Patient Profile | RelatedPerson)Subscriber to the policy　被保険者
... subscriberId 0..1stringID assigned to the subscriber　被保険者に割り当てられたID
... beneficiary 1..1Reference(JP Core Patient Profile)Plan beneficiary
... dependent 0..1string被保険者証 枝番
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber　加入者との受益者関係
... period 0..1PeriodCoverage start and end dates
... payor 1..*Reference(JP Core Organization Profile | JP Core Patient Profile | RelatedPerson)Issuer of the policy
... class 0..*BackboneElementAdditional coverage classifications
.... type 1..1CodeableConceptType of class such as 'group' or 'plan'
.... value 1..1stringValue associated with the type
.... name 0..1stringHuman readable description of the type and value
... order 0..1positiveIntRelative order of the coverage
... network 0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products　サービスやプロダクトに対する患者支払い
.... type 0..1CodeableConceptCost category
..... coding
...... system 0..1uriIdentity of the terminology system
...... code 0..1codeSymbol in syntax defined by the system
.... value[x] 1..1SimpleQuantity, MoneyThe amount or percentage due from the beneficiary
.... exception 0..*BackboneElementExceptions for patient payments
..... type 1..1CodeableConceptException category
..... period 0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer　保険者への償還
... contract 0..*Reference(Contract)Contract details　契約の詳細

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance 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 Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
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..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness 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 ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ0..1CodeableConceptCoverage 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 Σ0..1Reference(JP Core Patient Profile | RelatedPerson | JP Core Organization Profile)Owner of the policy　ポリシの所有者
... subscriber Σ0..1Reference(JP Core Patient Profile | RelatedPerson)Subscriber to the policy　被保険者
... subscriberId Σ0..1stringID assigned to the subscriber　被保険者に割り当てられたID
... beneficiary Σ1..1Reference(JP Core Patient Profile)Plan beneficiary
... dependent Σ0..1string被保険者証 枝番
... relationship 0..1CodeableConceptBeneficiary 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 Σ0..1PeriodCoverage start and end dates
... payor Σ1..*Reference(JP Core Organization Profile | JP Core Patient Profile | RelatedPerson)Issuer of the policy
... class 0..*BackboneElementAdditional coverage classifications
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

.... value Σ1..1stringValue associated with the type
.... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient 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..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ0..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ0..1uriIdentity of the terminology system
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ0..1codeSymbol in syntax defined by the system
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer　保険者への償還
... contract 0..*Reference(Contract)Contract details　契約の詳細

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance 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
... Slices for extension 0..*ExtensionExtension
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
... identifier 0..*IdentifierBusiness 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 1..1codeactive | cancelled | draft | entered-in-error
... type 0..1CodeableConceptCoverage category such as medical or accident　医療保険や事故補償のような分類
... policyHolder 0..1Reference(JP Core Patient Profile | RelatedPerson | JP Core Organization Profile)Owner of the policy　ポリシの所有者
... subscriber 0..1Reference(JP Core Patient Profile | RelatedPerson)Subscriber to the policy　被保険者
... subscriberId 0..1stringID assigned to the subscriber　被保険者に割り当てられたID
... beneficiary 1..1Reference(JP Core Patient Profile)Plan beneficiary
... dependent 0..1string被保険者証 枝番
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber　加入者との受益者関係
... period 0..1PeriodCoverage start and end dates
... payor 1..*Reference(JP Core Organization Profile | JP Core Patient Profile | RelatedPerson)Issuer of the policy
... class 0..*BackboneElementAdditional coverage classifications
.... type 1..1CodeableConceptType of class such as 'group' or 'plan'
.... value 1..1stringValue associated with the type
.... name 0..1stringHuman readable description of the type and value
... order 0..1positiveIntRelative order of the coverage
... network 0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products　サービスやプロダクトに対する患者支払い
.... type 0..1CodeableConceptCost category
..... coding
...... system 0..1uriIdentity of the terminology system
...... code 0..1codeSymbol in syntax defined by the system
.... value[x] 1..1SimpleQuantity, MoneyThe amount or percentage due from the beneficiary
.... exception 0..*BackboneElementExceptions for patient payments
..... type 1..1CodeableConceptException category
..... period 0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer　保険者への償還
... contract 0..*Reference(Contract)Contract details　契約の詳細

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance 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 Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
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..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness 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 ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ0..1CodeableConceptCoverage 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 Σ0..1Reference(JP Core Patient Profile | RelatedPerson | JP Core Organization Profile)Owner of the policy　ポリシの所有者
... subscriber Σ0..1Reference(JP Core Patient Profile | RelatedPerson)Subscriber to the policy　被保険者
... subscriberId Σ0..1stringID assigned to the subscriber　被保険者に割り当てられたID
... beneficiary Σ1..1Reference(JP Core Patient Profile)Plan beneficiary
... dependent Σ0..1string被保険者証 枝番
... relationship 0..1CodeableConceptBeneficiary 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 Σ0..1PeriodCoverage start and end dates
... payor Σ1..*Reference(JP Core Organization Profile | JP Core Patient Profile | RelatedPerson)Issuer of the policy
... class 0..*BackboneElementAdditional coverage classifications
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

.... value Σ1..1stringValue associated with the type
.... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient 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..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ0..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ0..1uriIdentity of the terminology system
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ0..1codeSymbol in syntax defined by the system
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer　保険者への償還
... contract 0..*Reference(Contract)Contract details　契約の詳細

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron

必須要素

Coverage リソースは、次の要素を必ず持たなければならない。

  • status ： 「リソースのインスタンスの状態」を示すエレメント
  • beneficiary : 「サービスを受ける者」を示すエレメント、Patientリソースを参照する
  • payor ： 「負担者」を示すエレメント。Organization、Patient、RelatedPersonのいずれかを参照する

Extensions定義

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。

利用方法

OperationおよびSearch Parameter 一覧

Search Parameter一覧

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=***
推奨検索パラメータ

次の検索パラメータをサポートすることが望ましい。

  1. 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。

  2. 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=*****

サンプル