HL7 FHIR JP Core ImplementationGuide
1.1.1 - ci-build Japan flag

HL7 FHIR JP Core ImplementationGuide - Local Development build (v1.1.1). See the Directory of published versions

Resource Profile: JP_Coverage - Detailed Descriptions

Active as of 2022-10-24

Definitions for the jp-coverage resource profile.

1. Coverage
Definition

Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.

ヘルスケア製品およびサービスの償還または支払いに使用される可能性のある金融商品。 保険と自己負担の両方が含まれる。

Comments

The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.

Coverageには、保険証レベルの情報が含まれている。これは、保険金請求やプロバイダと保険会社間のその他の通信で提供するのが通例である。

2. Coverage.extension
SlicingThis element introduces a set of slices on Coverage.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
3. Coverage.extension:insuredPersonSymbol
SliceNameinsuredPersonSymbol
Control0..*
TypeExtension(JP_Coverage_InsuredPersonSymbol) (Extension Type: string)
4. Coverage.extension:insuredPersonNumber
SliceNameinsuredPersonNumber
Control0..*
TypeExtension(JP_Coverage_InsuredPersonNumber) (Extension Type: string)
5. Coverage.extension:insuredPersonSubNumber
SliceNameinsuredPersonSubNumber
Control0..*
TypeExtension(JP_Coverage_InsuredPersonSubNumber) (Extension Type: string)
6. Coverage.identifier
Definition

A unique identifier assigned to this coverage.

このカバレッジに割り当てられた一意の識別子。

NoteThis is a business identifier, not a resource identifier (see discussion)
Requirements

Allows coverages to be distinguished and referenced.

カバレッジを区別して参照できるようにする。

Comments

The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependent.

カバレッジのメイン(および場合によっては唯一の)識別子-多くの場合、メンバID、証明書番号、個人の健康番号、またはケースIDと呼ばれる。

【JP Core仕様】被保険者記号と番号と枝番を全角にした上でダブルコーテーションで囲い、カンマ区切りで連結する。

ルール:"{被保険者記号}","{被保険者番号}","{枝番}"

例:"12-34","5678","00"

The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.

7. Coverage.status
Definition

The status of the resource instance.

リソースインスタンスのステータス。

Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

「ドラフト」リソースはさらに編集される可能性があり、「アクティブ」リソースは不変であり、ステータスが「キャンセル」に変更されるだけである可能性があるため、リソースのステータスを追跡する必要がある。

Comments

This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.

ステータスには、カバレッジが現在無効であることを示すエラー入力されたコードが含まれているため、この要素は修飾子としてラベル付けされる。

8. Coverage.type
Definition

The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.

補償の種類:社会プログラム、医療計画、事故補償(労働者災害補償、自動車)、グループの健康、または個人または組織による支払い。

Requirements

The order of application of coverages is dependent on the types of coverage.

カバレッジの適用順序は、カバレッジのタイプによって異なる。

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

すべてのターミノロジの使用がこの一般的なパターンに適合するわけではない。場合によっては、モデルはCodeableConceptを使用せず、コーディングを直接使用して、テキスト、コーディング、翻訳、および要素間の関係とpre-coordinationとpost-coordinationの用語関係を管理するための独自の構造を提供する必要がある。

【JP Core仕様】「処方情報 HL7FHIR 記述仕様」等で使用される保険種別コード(system=”urn:oid:1.2.392.100495.20.2.61”)として、https://www.mhlw.go.jp/content/10800000/000342368.pdf の別表11が使用している例があげられている。JP Coreとして本項目に対する用語のバインドは現時点では定義するまでに至っていない。

9. Coverage.policyHolder
Definition

The party who 'owns' the insurance policy.

保険証券を「所有する」当事者。

TypeReference(JP_Patient|RelatedPerson|JP_Organization|Patient|Organization))
Requirements

This provides employer information in the case of Worker's Compensation and other policies.

これは、労働者災害補償およびその他のポリシの場合に雇用者情報を提供する。

Comments

For example: may be an individual, corporation or the subscriber's employer.

例:個人、企業、または加入者の雇用主である可能性がある。

10. Coverage.subscriber
Definition

The party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due.

ポリシにサインアップした、またはポリシとの契約関係を「所有」している当事者、またはポリシの利益が彼らまたはその家族に提供されることになっている当事者。

TypeReference(JP_Patient|RelatedPerson|Patient))
Requirements

This is the party who is entitled to the benefits under the policy.

これは、ポリシに基づいて給付を受ける権利を有する当事者である。

This is the party who is entitled to the benfits under the policy.

Comments

May be self or a parent in the case of dependents.

扶養家族の場合、自己または親である可能性がある。

May be self or a parent in the case of dependants.

11. Coverage.subscriberId
Definition

The insurer assigned ID for the Subscriber.

被保険者に保険者が割り当てたID

Requirements

The insurer requires this identifier on correspondence and claims (digital and otherwise).

保険者は、連絡や請求(デジタルおよびその他)でこの識別子を要求する。 保険会社は、通信および請求(デジタルおよびその他)でこの識別子を要求する。

【JP Core仕様】被保険者記号と番号を全角にした上でダブルコーテーションで囲い、カンマ区切りで連結する。

ルール:"{被保険者記号}","{被保険者番号}"

例:"12-34","5678"

The insurer requires this identifier on correspondance and claims (digital and otherwise).

12. Coverage.beneficiary
Definition

The party who benefits from the insurance coverage; the patient when products and/or services are provided.

保険適用から利益を得る当事者、製品および/またはサービスが提供される際の患者。

TypeReference(JP_Patient|Patient))
Requirements

This is the party who receives treatment for which the costs are reimbursed under the coverage.

これは、補償の下で費用が償還される治療を受ける側のことである。

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

参照は、実際のFHIRリソースへの参照である必要があり、解決可能(内容に到達可能)である必要がある(アクセス制御、一時的な使用不可などを考慮に入れる)。解決は、URLから取得するか、リソースタイプによって該当する場合は、絶対参照を正規URLとして扱い、ローカルレジストリ/リポジトリで検索することによって行うことができる。

【JP Core仕様】患者Patientリソースへの参照。

13. Coverage.dependent
Definition

A unique identifier for a dependent under the coverage.

被保険者証の枝番。

Requirements

For some coverages a single identifier is issued to the Subscriber and then a unique dependent number is issued to each beneficiary.

一部の補償では、単一の識別子が加入者に発行され、次に一意の従属番号が各受益者に発行される。 一部の保険では、単一の識別子が加入者に発行され、その後、各受益者に固有の扶養番号が発行される。

【JP Core仕様】医療保険で本リソースを使用する場合には、この要素に拡張 InsuredPersonSubNumberに設定した値と同じ、被保険者番号の枝番号全角2桁を設定する。

例:"00"

Comments

Periodically the member number is constructed from the subscriberId and the dependent number.

被保険者証の枝番を全角で格納する。

Periodically the member number is constructed from the subscriberId and the dependant number.

14. Coverage.relationship
Definition

The relationship of beneficiary (patient) to the subscriber.

受益者(患者)と加入者の関係。

Requirements

To determine relationship between the patient and the subscriber to determine coordination of benefits.

患者と加入者の関係を決定し、給付の調整を決定する。

【JP Core仕様】「処方情報 HL7FHIR 記述仕様」等で使用される被保険者区分コード(system=”urn:oid:1.2.392.100495.20.2.62”)として、https://www.mhlw.go.jp/content/10800000/000342368.pdf の別表12が使用できる。 1 被保険者 2 被扶養者

Comments

Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.

一般的に、個人は、他人が所有するポリシよりも、自分のポリシ(relationship='self')を使用する。

15. Coverage.period
Definition

Time period during which the coverage is in force. A missing start date indicates the start date isn't known, a missing end date means the coverage is continuing to be in force.

補償範囲が有効である期間。開始日が欠落している場合は、開始日が不明であることを示す。終了日が欠落している場合は、補償範囲が引き続き有効であることを意味する。

Requirements

Some insurers require the submission of the coverage term.

保険会社によっては、補償期間の提出を義務付けているところもある。

Comments

A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.

Period(期間)は時間の範囲を指定する。使用状況は、範囲全体が適用されるか(たとえば、「患者はこの時間範囲で入院していた」)、範囲から1つの値が適用されるか(たとえば、「この2回の間に患者に投与する」)を指定する。 Period(期間)は、Duration(時間区間=経過時間の測定値)には使用されない。 [Duration](datatypes.html#Duration)を参照のこと。 This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). If duration is required, specify the type as Interval|Duration.

これはDuration(時間区間)ではない- Durationは時間の尺度(別のタイプ)だが、時間の固定値で発生する時間区間である。Period(期間)は時間の範囲を指定する。使用状況は、範囲全体が適用されるか(たとえば、「患者はこの時間範囲で入院していた」)、範囲から1つの値が適用されるか(たとえば、「この2回の間に患者に投与する」)を指定する。もし、Duration(時間区間)が必要な場合は、タイプをInterval | Durationとして指定する。 これは期間ではなく-これは時間の尺度(別のタイプ)あるが、時間の固定値で発生する期間である。期間は時間の範囲を指定する。使用状況は、範囲全体が適用されるか(たとえば、「患者はこの時間範囲で入院していた」)、または範囲から1つの値が適用されるか(たとえば、「これら2回の間に患者に与える」)を指定する。期間が必要な場合は、タイプをInterval | Durationとして指定する。

【JP Core仕様】医療保険、公費で本リソースを使用する場合には、保険証または公費の有効期間の開始日、終了日をstart とendに yyyy-mm-dd形式で設定する。

16. Coverage.payor
Definition

The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.

患者負担契約などの保険契約と保険外契約の両方を含むプログラムまたはプランの引受人または支払人。

TypeReference(JP_Organization|JP_Patient|RelatedPerson|Organization|Patient))
Requirements

Need to identify the issuer to target for claim processing and for coordination of benefit processing.

請求処理および給付処理の調整の対象となる発行者を特定する必要がある。

【JP Core仕様】医療保険で本リソースを使用する場合には、保険者組織Organizationリソースへの参照。自費の場合には、患者Patientリソースへの参照。公費の場合には、公費負担者組織Organizationリソースへの参照。

Comments

May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations.

保険会社の識別子や事業者の識別子(BIN番号)など、複数の識別子を提供してもよい。自己負担の場合は、複数の支払者および/または組織を提供してもよい。

17. Coverage.class
Definition

A suite of underwriter specific classifiers.

保険事業者の分類子

Requirements

The codes provided on the health card which identify or confirm the specific policy for the insurer.

健康カードに記載されているコードで、保険者の特定の保険契約を識別または確認するもの。

Comments

For example may be used to identify a class of coverage or employer group, Policy, Plan.

例えば、保険の種類または雇用者グループ、保険契約、Planを識別するために使用することができる。

18. Coverage.class.type
Definition

The type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan.

保険者固有のクラスラベルまたは番号、任意の名前が提供されている分類のタイプを表す。例えば、保険のクラスまたは雇用者グループ、保険契約、Planを識別するために使用することができる。

Requirements

The insurer issued label for a specific health card value.

保険者が発行した特定の健康カード番号のラベル。

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

すべての用語の使用がこの一般的なパターンに適合するわけではない。いくつかのケースでは、モデルはCodeableConceptを使用せず、Codingを直接使用し、テキスト、コーディング、翻訳、要素間の関係、および前後の調整を管理するための独自の構造を提供することが望ましい。

19. Coverage.class.value
Definition

The alphanumeric string value associated with the insurer issued label.

保険者が発行したラベルに関連付けられた英数字の文字列値。

Requirements

The insurer issued label and value are necessary to identify the specific policy.

保険者が発行したラベルと値は、特定の保険契約を識別するために必要なものである。

Comments

For example, the Group or Plan number.

例えば、グループ番号やプラン番号など。

20. Coverage.class.name
Definition

A short description for the class.

保険種類の簡単な説明。

Requirements

Used to provide a meaningful description in correspondence to the patient.

患者に対応するのに意味のある説明をするために使用する。

21. Coverage.order
Definition

The order of applicability of this coverage relative to other coverages which are currently in force. Note, there may be gaps in the numbering and this does not imply primary, secondary etc. as the specific positioning of coverages depends upon the episode of care.

現在適用されている他の保障と比較して、この保障の適用可能性が高い順に記載されている。なお、ナンバリングにギャップがある場合があり、カバーの具体的な位置づけはケアのエピソードに依存するため、一次、二次などを意味するものではない。

Requirements

Used in managing the coordination of benefits.

保険給付の調整管理に使用する。

【JP Core仕様】公費情報で本リソースを使用する場合で、複数の公費負担情報がある場合に、その適用順序番号を示す1,2,3...を設定する。

Comments

32 bit number; for values larger than this, use decimal

32 ビットの数値、これより大きい値の場合は 10 進数を使用する。

22. Coverage.network
Definition

The insurer-specific identifier for the insurer-defined network of providers to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply.

保険者が定義したプロバイダの保険者定義ネットワークの保険者固有の識別子で、被保険者が「ネットワーク内」の料金でカバーされる治療を受けることができるが、そうでなければ「ネットワーク外」の条件が適用される。

Requirements

Used in referral for treatment and in claims processing.

治療のための紹介や請求処理の際に使用する。

23. Coverage.costToBeneficiary
Definition

A suite of codes indicating the cost category and associated amount which have been detailed in the policy and may have been included on the health card.

ポリシに詳細が記載されており、ヘルスカードに含まれている可能性のあるコストカテゴリと関連する金額を示す一連のコード。

Requirements

Required by providers to manage financial transaction with the patient.

事業者が患者との金銭的な取引を管理するために必要となる。

Comments

For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.

例えば、患者の訪問時の自己負担額を知ることで、医療提供者は治療を行う前にその金額を回収することができる。

【JP Core仕様】公費の場合には自己負担率。判明している場合のみ設定する。

24. Coverage.costToBeneficiary.type
Definition

The category of patient centric costs associated with treatment.

治療に伴う患者中心の費用のカテゴリー。

Requirements

Needed to identify the category associated with the amount for the patient.

患者の金額に関連するカテゴリーを特定する必要がありました。

Comments

For example visit, specialist visits, emergency, inpatient care, etc.

例えば、訪問診療、専門医の訪問診療、救急診療、入院診療など。

25. Coverage.costToBeneficiary.type.coding
Control0..?
26. Coverage.costToBeneficiary.type.coding.system
Control0..?
Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

保険や公費における自己負担率の種別を識別するコード体系のコード。 "http://terminology.hl7.org/CodeSystem/coverage-copay-type"

27. Coverage.costToBeneficiary.type.coding.code
Control0..?
Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

自己負担率を表すコード "copaypct"

28. Coverage.costToBeneficiary.value[x]
Definition

The amount due from the patient for the cost category.

費用区分の患者からの支払額。

[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Needed to identify the amount for the patient associated with the category.

カテゴリーに関連する患者の支払い金額を特定する必要がありました。

Comments

Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.

金額は、サービス/製品のコストに対する割合で表現される場合と、通貨の固定額で表現される場合がある。

29. Coverage.costToBeneficiary.exception
Definition

A suite of codes indicating exceptions or reductions to patient costs and their effective periods.

患者費用の例外または削減を示すコードとその有効期間を示すコード群。

Requirements

Required by providers to manage financial transaction with the patient.

事業者が患者との金銭的な取引を管理するために必要となる。

30. Coverage.costToBeneficiary.exception.type
Definition

The code for the specific exception.

特定の例外のコード。

Requirements

Needed to identify the exception associated with the amount for the patient.

患者の金額に関連する例外を特定する必要があった。

31. Coverage.costToBeneficiary.exception.period
Definition

The timeframe during when the exception is in force.

例外が発生している間の時間枠。

Requirements

Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs.

患者の費用を正しく計算するための例外の適用時期を特定する必要があった。

32. Coverage.subrogation
Definition

When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs.

subrogation=trueの場合、この保険インスタンスは裁定のためではなく、保険者に費用回収のための詳細を提供するために含まれている。 (subrogation=代位、subrogation payment=代位納付)

Requirements

See definition for when to be used.

使用時期については定義を参照すること。

Comments

Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.

一般的に、自動車保険や労災保険では、医療費支払い者が事故請求に対して回収できるように、subrogation=true というフラグが立てられている。

33. Coverage.contract
Definition

The policy(s) which constitute this insurance coverage.

この保険の適用範囲を構成するポリシ。

Requirements

To reference the legally binding contract between the policy holder and the insurer.

契約者と保険者との間の法的拘束力のある契約を参照するため。

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

参照は、実際のFHIRリソースへの参照である必要があり、解決可能(内容に到達可能)である必要がある(アクセス制御、一時的な使用不可などを考慮に入れる)。解決は、URLから取得するか、リソースタイプによって該当する場合は、絶対参照を正規URLとして扱い、ローカルレジストリ/リポジトリで検索することによって行うことができる。

1. Coverage
Definition

Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.

ヘルスケア製品およびサービスの償還または支払いに使用される可能性のある金融商品。 保険と自己負担の両方が含まれる。

Control0..*
Comments

The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.

Coverageには、保険証レベルの情報が含まれている。これは、保険金請求やプロバイダと保険会社間のその他の通信で提供するのが通例である。

InvariantsDefined on this element
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty())
dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (: contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (: text.`div`.exists())
2. Coverage.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Control0..1
Typeuri
Is Modifiertrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
3. Coverage.extension
Definition

An Extension

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
SlicingThis element introduces a set of slices on Coverage.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
4. Coverage.extension:insuredPersonSymbol
SliceNameinsuredPersonSymbol
Definition

健康保険における被保険者証記号を示す拡張

Control0..* This element is affected by the following invariants: ele-1
TypeExtension(JP_Coverage_InsuredPersonSymbol) (Extension Type: string)
Comments

健康保険における被保険者証記号を示す拡張。被保険者記号の全角文字列。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
5. Coverage.extension:insuredPersonNumber
SliceNameinsuredPersonNumber
Definition

健康保険における被保険者証番号を示す拡張

Control0..* This element is affected by the following invariants: ele-1
TypeExtension(JP_Coverage_InsuredPersonNumber) (Extension Type: string)
Comments

健康保険における被保険者証番号を示す拡張。被保険者記号の全角文字列。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
6. Coverage.extension:insuredPersonSubNumber
SliceNameinsuredPersonSubNumber
Definition

健康保険における被保険者証番号の枝番を示す拡張

Control0..* This element is affected by the following invariants: ele-1
TypeExtension(JP_Coverage_InsuredPersonSubNumber) (Extension Type: string)
Comments

健康保険における被保険者証番号を示す拡張。2桁の全角数字文字列。一桁の場合には先頭に0をつけて2桁にする。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
7. Coverage.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
8. Coverage.identifier
Definition

A unique identifier assigned to this coverage.

このカバレッジに割り当てられた一意の識別子。

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Allows coverages to be distinguished and referenced.

カバレッジを区別して参照できるようにする。

Comments

The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependent.

カバレッジのメイン(および場合によっては唯一の)識別子-多くの場合、メンバID、証明書番号、個人の健康番号、またはケースIDと呼ばれる。

【JP Core仕様】被保険者記号と番号と枝番を全角にした上でダブルコーテーションで囲い、カンマ区切りで連結する。

ルール:"{被保険者記号}","{被保険者番号}","{枝番}"

例:"12-34","5678","00"

The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
9. Coverage.status
Definition

The status of the resource instance.

リソースインスタンスのステータス。

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodes

A code specifying the state of the resource instance.

Typecode
Is Modifiertrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

「ドラフト」リソースはさらに編集される可能性があり、「アクティブ」リソースは不変であり、ステータスが「キャンセル」に変更されるだけである可能性があるため、リソースのステータスを追跡する必要がある。

Comments

This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.

ステータスには、カバレッジが現在無効であることを示すエラー入力されたコードが含まれているため、この要素は修飾子としてラベル付けされる。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
10. Coverage.type
Definition

The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.

補償の種類:社会プログラム、医療計画、事故補償(労働者災害補償、自動車)、グループの健康、または個人または組織による支払い。

Control0..1
BindingThe codes SHOULD be taken from CoverageTypeAndSelf-PayCodes

The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.

TypeCodeableConcept
Requirements

The order of application of coverages is dependent on the types of coverage.

カバレッジの適用順序は、カバレッジのタイプによって異なる。

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

すべてのターミノロジの使用がこの一般的なパターンに適合するわけではない。場合によっては、モデルはCodeableConceptを使用せず、コーディングを直接使用して、テキスト、コーディング、翻訳、および要素間の関係とpre-coordinationとpost-coordinationの用語関係を管理するための独自の構造を提供する必要がある。

【JP Core仕様】「処方情報 HL7FHIR 記述仕様」等で使用される保険種別コード(system=”urn:oid:1.2.392.100495.20.2.61”)として、https://www.mhlw.go.jp/content/10800000/000342368.pdf の別表11が使用している例があげられている。JP Coreとして本項目に対する用語のバインドは現時点では定義するまでに至っていない。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
11. Coverage.policyHolder
Definition

The party who 'owns' the insurance policy.

保険証券を「所有する」当事者。

Control0..1
TypeReference(JP_Patient|RelatedPerson|JP_Organization|Patient|Organization))
Requirements

This provides employer information in the case of Worker's Compensation and other policies.

これは、労働者災害補償およびその他のポリシの場合に雇用者情報を提供する。

Comments

For example: may be an individual, corporation or the subscriber's employer.

例:個人、企業、または加入者の雇用主である可能性がある。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
12. Coverage.subscriber
Definition

The party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due.

ポリシにサインアップした、またはポリシとの契約関係を「所有」している当事者、またはポリシの利益が彼らまたはその家族に提供されることになっている当事者。

Control0..1
TypeReference(JP_Patient|RelatedPerson|Patient))
Requirements

This is the party who is entitled to the benefits under the policy.

これは、ポリシに基づいて給付を受ける権利を有する当事者である。

This is the party who is entitled to the benfits under the policy.

Comments

May be self or a parent in the case of dependents.

扶養家族の場合、自己または親である可能性がある。

May be self or a parent in the case of dependants.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
13. Coverage.subscriberId
Definition

The insurer assigned ID for the Subscriber.

被保険者に保険者が割り当てたID

Control0..1
Typestring
Requirements

The insurer requires this identifier on correspondence and claims (digital and otherwise).

保険者は、連絡や請求(デジタルおよびその他)でこの識別子を要求する。 保険会社は、通信および請求(デジタルおよびその他)でこの識別子を要求する。

【JP Core仕様】被保険者記号と番号を全角にした上でダブルコーテーションで囲い、カンマ区切りで連結する。

ルール:"{被保険者記号}","{被保険者番号}"

例:"12-34","5678"

The insurer requires this identifier on correspondance and claims (digital and otherwise).

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
14. Coverage.beneficiary
Definition

The party who benefits from the insurance coverage; the patient when products and/or services are provided.

保険適用から利益を得る当事者、製品および/またはサービスが提供される際の患者。

Control1..1
TypeReference(JP_Patient|Patient))
Requirements

This is the party who receives treatment for which the costs are reimbursed under the coverage.

これは、補償の下で費用が償還される治療を受ける側のことである。

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

参照は、実際のFHIRリソースへの参照である必要があり、解決可能(内容に到達可能)である必要がある(アクセス制御、一時的な使用不可などを考慮に入れる)。解決は、URLから取得するか、リソースタイプによって該当する場合は、絶対参照を正規URLとして扱い、ローカルレジストリ/リポジトリで検索することによって行うことができる。

【JP Core仕様】患者Patientリソースへの参照。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
15. Coverage.dependent
Definition

A unique identifier for a dependent under the coverage.

被保険者証の枝番。

Control0..1
Typestring
Requirements

For some coverages a single identifier is issued to the Subscriber and then a unique dependent number is issued to each beneficiary.

一部の補償では、単一の識別子が加入者に発行され、次に一意の従属番号が各受益者に発行される。 一部の保険では、単一の識別子が加入者に発行され、その後、各受益者に固有の扶養番号が発行される。

【JP Core仕様】医療保険で本リソースを使用する場合には、この要素に拡張 InsuredPersonSubNumberに設定した値と同じ、被保険者番号の枝番号全角2桁を設定する。

例:"00"

Comments

Periodically the member number is constructed from the subscriberId and the dependent number.

被保険者証の枝番を全角で格納する。

Periodically the member number is constructed from the subscriberId and the dependant number.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
16. Coverage.relationship
Definition

The relationship of beneficiary (patient) to the subscriber.

受益者(患者)と加入者の関係。

Control0..1
BindingThe codes SHALL be taken from SubscriberRelationshipCodes; other codes may be used where these codes are not suitable

The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

TypeCodeableConcept
Requirements

To determine relationship between the patient and the subscriber to determine coordination of benefits.

患者と加入者の関係を決定し、給付の調整を決定する。

【JP Core仕様】「処方情報 HL7FHIR 記述仕様」等で使用される被保険者区分コード(system=”urn:oid:1.2.392.100495.20.2.62”)として、https://www.mhlw.go.jp/content/10800000/000342368.pdf の別表12が使用できる。 1 被保険者 2 被扶養者

Comments

Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.

一般的に、個人は、他人が所有するポリシよりも、自分のポリシ(relationship='self')を使用する。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
17. Coverage.period
Definition

Time period during which the coverage is in force. A missing start date indicates the start date isn't known, a missing end date means the coverage is continuing to be in force.

補償範囲が有効である期間。開始日が欠落している場合は、開始日が不明であることを示す。終了日が欠落している場合は、補償範囲が引き続き有効であることを意味する。

Control0..1
TypePeriod
Requirements

Some insurers require the submission of the coverage term.

保険会社によっては、補償期間の提出を義務付けているところもある。

Comments

A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.

Period(期間)は時間の範囲を指定する。使用状況は、範囲全体が適用されるか(たとえば、「患者はこの時間範囲で入院していた」)、範囲から1つの値が適用されるか(たとえば、「この2回の間に患者に投与する」)を指定する。 Period(期間)は、Duration(時間区間=経過時間の測定値)には使用されない。 [Duration](datatypes.html#Duration)を参照のこと。 This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). If duration is required, specify the type as Interval|Duration.

これはDuration(時間区間)ではない- Durationは時間の尺度(別のタイプ)だが、時間の固定値で発生する時間区間である。Period(期間)は時間の範囲を指定する。使用状況は、範囲全体が適用されるか(たとえば、「患者はこの時間範囲で入院していた」)、範囲から1つの値が適用されるか(たとえば、「この2回の間に患者に投与する」)を指定する。もし、Duration(時間区間)が必要な場合は、タイプをInterval | Durationとして指定する。 これは期間ではなく-これは時間の尺度(別のタイプ)あるが、時間の固定値で発生する期間である。期間は時間の範囲を指定する。使用状況は、範囲全体が適用されるか(たとえば、「患者はこの時間範囲で入院していた」)、または範囲から1つの値が適用されるか(たとえば、「これら2回の間に患者に与える」)を指定する。期間が必要な場合は、タイプをInterval | Durationとして指定する。

【JP Core仕様】医療保険、公費で本リソースを使用する場合には、保険証または公費の有効期間の開始日、終了日をstart とendに yyyy-mm-dd形式で設定する。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
18. Coverage.payor
Definition

The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.

患者負担契約などの保険契約と保険外契約の両方を含むプログラムまたはプランの引受人または支払人。

Control1..*
TypeReference(JP_Organization|JP_Patient|RelatedPerson|Organization|Patient))
Requirements

Need to identify the issuer to target for claim processing and for coordination of benefit processing.

請求処理および給付処理の調整の対象となる発行者を特定する必要がある。

【JP Core仕様】医療保険で本リソースを使用する場合には、保険者組織Organizationリソースへの参照。自費の場合には、患者Patientリソースへの参照。公費の場合には、公費負担者組織Organizationリソースへの参照。

Comments

May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations.

保険会社の識別子や事業者の識別子(BIN番号)など、複数の識別子を提供してもよい。自己負担の場合は、複数の支払者および/または組織を提供してもよい。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
19. Coverage.class
Definition

A suite of underwriter specific classifiers.

保険事業者の分類子

Control0..*
TypeBackboneElement
Requirements

The codes provided on the health card which identify or confirm the specific policy for the insurer.

健康カードに記載されているコードで、保険者の特定の保険契約を識別または確認するもの。

Comments

For example may be used to identify a class of coverage or employer group, Policy, Plan.

例えば、保険の種類または雇用者グループ、保険契約、Planを識別するために使用することができる。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
20. Coverage.class.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
21. Coverage.class.type
Definition

The type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan.

保険者固有のクラスラベルまたは番号、任意の名前が提供されている分類のタイプを表す。例えば、保険のクラスまたは雇用者グループ、保険契約、Planを識別するために使用することができる。

Control1..1
BindingThe codes SHALL be taken from CoverageClassCodes; other codes may be used where these codes are not suitable

The policy classifications, eg. Group, Plan, Class, etc.

TypeCodeableConcept
Requirements

The insurer issued label for a specific health card value.

保険者が発行した特定の健康カード番号のラベル。

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

すべての用語の使用がこの一般的なパターンに適合するわけではない。いくつかのケースでは、モデルはCodeableConceptを使用せず、Codingを直接使用し、テキスト、コーディング、翻訳、要素間の関係、および前後の調整を管理するための独自の構造を提供することが望ましい。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
22. Coverage.class.value
Definition

The alphanumeric string value associated with the insurer issued label.

保険者が発行したラベルに関連付けられた英数字の文字列値。

Control1..1
Typestring
Requirements

The insurer issued label and value are necessary to identify the specific policy.

保険者が発行したラベルと値は、特定の保険契約を識別するために必要なものである。

Comments

For example, the Group or Plan number.

例えば、グループ番号やプラン番号など。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
23. Coverage.class.name
Definition

A short description for the class.

保険種類の簡単な説明。

Control0..1
Typestring
Requirements

Used to provide a meaningful description in correspondence to the patient.

患者に対応するのに意味のある説明をするために使用する。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
24. Coverage.order
Definition

The order of applicability of this coverage relative to other coverages which are currently in force. Note, there may be gaps in the numbering and this does not imply primary, secondary etc. as the specific positioning of coverages depends upon the episode of care.

現在適用されている他の保障と比較して、この保障の適用可能性が高い順に記載されている。なお、ナンバリングにギャップがある場合があり、カバーの具体的な位置づけはケアのエピソードに依存するため、一次、二次などを意味するものではない。

Control0..1
TypepositiveInt
Requirements

Used in managing the coordination of benefits.

保険給付の調整管理に使用する。

【JP Core仕様】公費情報で本リソースを使用する場合で、複数の公費負担情報がある場合に、その適用順序番号を示す1,2,3...を設定する。

Comments

32 bit number; for values larger than this, use decimal

32 ビットの数値、これより大きい値の場合は 10 進数を使用する。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
25. Coverage.network
Definition

The insurer-specific identifier for the insurer-defined network of providers to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply.

保険者が定義したプロバイダの保険者定義ネットワークの保険者固有の識別子で、被保険者が「ネットワーク内」の料金でカバーされる治療を受けることができるが、そうでなければ「ネットワーク外」の条件が適用される。

Control0..1
Typestring
Requirements

Used in referral for treatment and in claims processing.

治療のための紹介や請求処理の際に使用する。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
26. Coverage.costToBeneficiary
Definition

A suite of codes indicating the cost category and associated amount which have been detailed in the policy and may have been included on the health card.

ポリシに詳細が記載されており、ヘルスカードに含まれている可能性のあるコストカテゴリと関連する金額を示す一連のコード。

Control0..*
TypeBackboneElement
Requirements

Required by providers to manage financial transaction with the patient.

事業者が患者との金銭的な取引を管理するために必要となる。

Alternate NamesCoPay, Deductible, Exceptions
Comments

For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.

例えば、患者の訪問時の自己負担額を知ることで、医療提供者は治療を行う前にその金額を回収することができる。

【JP Core仕様】公費の場合には自己負担率。判明している場合のみ設定する。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
27. Coverage.costToBeneficiary.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
28. Coverage.costToBeneficiary.type
Definition

The category of patient centric costs associated with treatment.

治療に伴う患者中心の費用のカテゴリー。

Control0..1
BindingThe codes SHALL be taken from CoverageCopayTypeCodes; other codes may be used where these codes are not suitable

The types of services to which patient copayments are specified.

TypeCodeableConcept
Requirements

Needed to identify the category associated with the amount for the patient.

患者の金額に関連するカテゴリーを特定する必要がありました。

Comments

For example visit, specialist visits, emergency, inpatient care, etc.

例えば、訪問診療、専門医の訪問診療、救急診療、入院診療など。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
29. Coverage.costToBeneficiary.value[x]
Definition

The amount due from the patient for the cost category.

費用区分の患者からの支払額。

Control1..1
TypeChoice of: Quantity(SimpleQuantity), Money
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Needed to identify the amount for the patient associated with the category.

カテゴリーに関連する患者の支払い金額を特定する必要がありました。

Comments

Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.

金額は、サービス/製品のコストに対する割合で表現される場合と、通貨の固定額で表現される場合がある。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
30. Coverage.costToBeneficiary.exception
Definition

A suite of codes indicating exceptions or reductions to patient costs and their effective periods.

患者費用の例外または削減を示すコードとその有効期間を示すコード群。

Control0..*
TypeBackboneElement
Requirements

Required by providers to manage financial transaction with the patient.

事業者が患者との金銭的な取引を管理するために必要となる。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
31. Coverage.costToBeneficiary.exception.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
32. Coverage.costToBeneficiary.exception.type
Definition

The code for the specific exception.

特定の例外のコード。

Control1..1
BindingFor example codes, see ExampleCoverageFinancialExceptionCodes

The types of exceptions from the part or full value of financial obligations such as copays.

TypeCodeableConcept
Requirements

Needed to identify the exception associated with the amount for the patient.

患者の金額に関連する例外を特定する必要があった。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
33. Coverage.costToBeneficiary.exception.period
Definition

The timeframe during when the exception is in force.

例外が発生している間の時間枠。

Control0..1
TypePeriod
Requirements

Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs.

患者の費用を正しく計算するための例外の適用時期を特定する必要があった。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
34. Coverage.subrogation
Definition

When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs.

subrogation=trueの場合、この保険インスタンスは裁定のためではなく、保険者に費用回収のための詳細を提供するために含まれている。 (subrogation=代位、subrogation payment=代位納付)

Control0..1
Typeboolean
Requirements

See definition for when to be used.

使用時期については定義を参照すること。

Comments

Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.

一般的に、自動車保険や労災保険では、医療費支払い者が事故請求に対して回収できるように、subrogation=true というフラグが立てられている。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
35. Coverage.contract
Definition

The policy(s) which constitute this insurance coverage.

この保険の適用範囲を構成するポリシ。

Control0..*
TypeReference(Contract))
Requirements

To reference the legally binding contract between the policy holder and the insurer.

契約者と保険者との間の法的拘束力のある契約を参照するため。

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

参照は、実際のFHIRリソースへの参照である必要があり、解決可能(内容に到達可能)である必要がある(アクセス制御、一時的な使用不可などを考慮に入れる)。解決は、URLから取得するか、リソースタイプによって該当する場合は、絶対参照を正規URLとして扱い、ローカルレジストリ/リポジトリで検索することによって行うことができる。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
1. Coverage
Definition

Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.

ヘルスケア製品およびサービスの償還または支払いに使用される可能性のある金融商品。 保険と自己負担の両方が含まれる。

Control0..*
Comments

The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.

Coverageには、保険証レベルの情報が含まれている。これは、保険金請求やプロバイダと保険会社間のその他の通信で提供するのが通例である。

2. Coverage.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typeid
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

3. Coverage.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Control0..1
TypeMeta
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
4. Coverage.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Control0..1
Typeuri
Is Modifiertrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
5. Coverage.language
Definition

The base language in which the resource is written.

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages A human language
Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
6. Coverage.text
Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
TypeNarrative
Alternate Namesnarrativehtmlxhtmldisplay
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
7. Coverage.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Control0..*
TypeResource
Alternate Namesinline resourcesanonymous resourcescontained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

8. Coverage.extension
Definition

An Extension

Control0..*
TypeExtension
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
SlicingThis element introduces a set of slices on Coverage.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
9. Coverage.extension:insuredPersonSymbol
SliceNameinsuredPersonSymbol
Definition

健康保険における被保険者証記号を示す拡張

Control0..* This element is affected by the following invariants: ele-1
TypeExtension(JP_Coverage_InsuredPersonSymbol) (Extension Type: string)
Comments

健康保険における被保険者証記号を示す拡張。被保険者記号の全角文字列。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
10. Coverage.extension:insuredPersonNumber
SliceNameinsuredPersonNumber
Definition

健康保険における被保険者証番号を示す拡張

Control0..* This element is affected by the following invariants: ele-1
TypeExtension(JP_Coverage_InsuredPersonNumber) (Extension Type: string)
Comments

健康保険における被保険者証番号を示す拡張。被保険者記号の全角文字列。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
11. Coverage.extension:insuredPersonSubNumber
SliceNameinsuredPersonSubNumber
Definition

健康保険における被保険者証番号の枝番を示す拡張

Control0..* This element is affected by the following invariants: ele-1
TypeExtension(JP_Coverage_InsuredPersonSubNumber) (Extension Type: string)
Comments

健康保険における被保険者証番号を示す拡張。2桁の全角数字文字列。一桁の場合には先頭に0をつけて2桁にする。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
12. Coverage.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
13. Coverage.identifier
Definition

A unique identifier assigned to this coverage.

このカバレッジに割り当てられた一意の識別子。

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Allows coverages to be distinguished and referenced.

カバレッジを区別して参照できるようにする。

Comments

The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependent.

カバレッジのメイン(および場合によっては唯一の)識別子-多くの場合、メンバID、証明書番号、個人の健康番号、またはケースIDと呼ばれる。

【JP Core仕様】被保険者記号と番号と枝番を全角にした上でダブルコーテーションで囲い、カンマ区切りで連結する。

ルール:"{被保険者記号}","{被保険者番号}","{枝番}"

例:"12-34","5678","00"

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
14. Coverage.status
Definition

The status of the resource instance.

リソースインスタンスのステータス。

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodes A code specifying the state of the resource instance
Typecode
Is Modifiertrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

「ドラフト」リソースはさらに編集される可能性があり、「アクティブ」リソースは不変であり、ステータスが「キャンセル」に変更されるだけである可能性があるため、リソースのステータスを追跡する必要がある。

Comments

This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.

ステータスには、カバレッジが現在無効であることを示すエラー入力されたコードが含まれているため、この要素は修飾子としてラベル付けされる。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
15. Coverage.type
Definition

The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.

補償の種類:社会プログラム、医療計画、事故補償(労働者災害補償、自動車)、グループの健康、または個人または組織による支払い。

Control0..1
BindingThe codes SHOULD be taken from CoverageTypeAndSelf-PayCodes The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization
TypeCodeableConcept
Requirements

The order of application of coverages is dependent on the types of coverage.

カバレッジの適用順序は、カバレッジのタイプによって異なる。

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

すべてのターミノロジの使用がこの一般的なパターンに適合するわけではない。場合によっては、モデルはCodeableConceptを使用せず、コーディングを直接使用して、テキスト、コーディング、翻訳、および要素間の関係とpre-coordinationとpost-coordinationの用語関係を管理するための独自の構造を提供する必要がある。

【JP Core仕様】「処方情報 HL7FHIR 記述仕様」等で使用される保険種別コード(system=”urn:oid:1.2.392.100495.20.2.61”)として、https://www.mhlw.go.jp/content/10800000/000342368.pdf の別表11が使用している例があげられている。JP Coreとして本項目に対する用語のバインドは現時点では定義するまでに至っていない。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
16. Coverage.policyHolder
Definition

The party who 'owns' the insurance policy.

保険証券を「所有する」当事者。

Control0..1
TypeReference(JP_PatientRelatedPersonJP_Organization))
Requirements

This provides employer information in the case of Worker's Compensation and other policies.

これは、労働者災害補償およびその他のポリシの場合に雇用者情報を提供する。

Comments

For example: may be an individual, corporation or the subscriber's employer.

例:個人、企業、または加入者の雇用主である可能性がある。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
17. Coverage.subscriber
Definition

The party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due.

ポリシにサインアップした、またはポリシとの契約関係を「所有」している当事者、またはポリシの利益が彼らまたはその家族に提供されることになっている当事者。

Control0..1
TypeReference(JP_PatientRelatedPerson))
Requirements

This is the party who is entitled to the benefits under the policy.

これは、ポリシに基づいて給付を受ける権利を有する当事者である。

Comments

May be self or a parent in the case of dependents.

扶養家族の場合、自己または親である可能性がある。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
18. Coverage.subscriberId
Definition

The insurer assigned ID for the Subscriber.

被保険者に保険者が割り当てたID

Control0..1
Typestring
Requirements

The insurer requires this identifier on correspondence and claims (digital and otherwise).

保険者は、連絡や請求(デジタルおよびその他)でこの識別子を要求する。 保険会社は、通信および請求(デジタルおよびその他)でこの識別子を要求する。

【JP Core仕様】被保険者記号と番号を全角にした上でダブルコーテーションで囲い、カンマ区切りで連結する。

ルール:"{被保険者記号}","{被保険者番号}"

例:"12-34","5678"

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
19. Coverage.beneficiary
Definition

The party who benefits from the insurance coverage; the patient when products and/or services are provided.

保険適用から利益を得る当事者、製品および/またはサービスが提供される際の患者。

Control1..1
TypeReference(JP_Patient))
Requirements

This is the party who receives treatment for which the costs are reimbursed under the coverage.

これは、補償の下で費用が償還される治療を受ける側のことである。

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

参照は、実際のFHIRリソースへの参照である必要があり、解決可能(内容に到達可能)である必要がある(アクセス制御、一時的な使用不可などを考慮に入れる)。解決は、URLから取得するか、リソースタイプによって該当する場合は、絶対参照を正規URLとして扱い、ローカルレジストリ/リポジトリで検索することによって行うことができる。

【JP Core仕様】患者Patientリソースへの参照。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
20. Coverage.dependent
Definition

A unique identifier for a dependent under the coverage.

被保険者証の枝番。

Control0..1
Typestring
Requirements

For some coverages a single identifier is issued to the Subscriber and then a unique dependent number is issued to each beneficiary.

一部の補償では、単一の識別子が加入者に発行され、次に一意の従属番号が各受益者に発行される。 一部の保険では、単一の識別子が加入者に発行され、その後、各受益者に固有の扶養番号が発行される。

【JP Core仕様】医療保険で本リソースを使用する場合には、この要素に拡張 InsuredPersonSubNumberに設定した値と同じ、被保険者番号の枝番号全角2桁を設定する。

例:"00"

Comments

Periodically the member number is constructed from the subscriberId and the dependent number.

被保険者証の枝番を全角で格納する。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
21. Coverage.relationship
Definition

The relationship of beneficiary (patient) to the subscriber.

受益者(患者)と加入者の関係。

Control0..1
BindingThe codes SHALL be taken from SubscriberRelationshipCodes; other codes may be used where these codes are not suitable The relationship between the Subscriber and the Beneficiary (insured/covered party/patient)
TypeCodeableConcept
Requirements

To determine relationship between the patient and the subscriber to determine coordination of benefits.

患者と加入者の関係を決定し、給付の調整を決定する。

【JP Core仕様】「処方情報 HL7FHIR 記述仕様」等で使用される被保険者区分コード(system=”urn:oid:1.2.392.100495.20.2.62”)として、https://www.mhlw.go.jp/content/10800000/000342368.pdf の別表12が使用できる。 1 被保険者 2 被扶養者

Comments

Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.

一般的に、個人は、他人が所有するポリシよりも、自分のポリシ(relationship='self')を使用する。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
22. Coverage.period
Definition

Time period during which the coverage is in force. A missing start date indicates the start date isn't known, a missing end date means the coverage is continuing to be in force.

補償範囲が有効である期間。開始日が欠落している場合は、開始日が不明であることを示す。終了日が欠落している場合は、補償範囲が引き続き有効であることを意味する。

Control0..1
TypePeriod
Requirements

Some insurers require the submission of the coverage term.

保険会社によっては、補償期間の提出を義務付けているところもある。

Comments

A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.

Period(期間)は時間の範囲を指定する。使用状況は、範囲全体が適用されるか(たとえば、「患者はこの時間範囲で入院していた」)、範囲から1つの値が適用されるか(たとえば、「この2回の間に患者に投与する」)を指定する。 Period(期間)は、Duration(時間区間=経過時間の測定値)には使用されない。 [Duration](datatypes.html#Duration)を参照のこと。 This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). If duration is required, specify the type as Interval|Duration.

これはDuration(時間区間)ではない- Durationは時間の尺度(別のタイプ)だが、時間の固定値で発生する時間区間である。Period(期間)は時間の範囲を指定する。使用状況は、範囲全体が適用されるか(たとえば、「患者はこの時間範囲で入院していた」)、範囲から1つの値が適用されるか(たとえば、「この2回の間に患者に投与する」)を指定する。もし、Duration(時間区間)が必要な場合は、タイプをInterval | Durationとして指定する。 これは期間ではなく-これは時間の尺度(別のタイプ)あるが、時間の固定値で発生する期間である。期間は時間の範囲を指定する。使用状況は、範囲全体が適用されるか(たとえば、「患者はこの時間範囲で入院していた」)、または範囲から1つの値が適用されるか(たとえば、「これら2回の間に患者に与える」)を指定する。期間が必要な場合は、タイプをInterval | Durationとして指定する。

【JP Core仕様】医療保険、公費で本リソースを使用する場合には、保険証または公費の有効期間の開始日、終了日をstart とendに yyyy-mm-dd形式で設定する。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
23. Coverage.payor
Definition

The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.

患者負担契約などの保険契約と保険外契約の両方を含むプログラムまたはプランの引受人または支払人。

Control1..*
TypeReference(JP_OrganizationJP_PatientRelatedPerson))
Requirements

Need to identify the issuer to target for claim processing and for coordination of benefit processing.

請求処理および給付処理の調整の対象となる発行者を特定する必要がある。

【JP Core仕様】医療保険で本リソースを使用する場合には、保険者組織Organizationリソースへの参照。自費の場合には、患者Patientリソースへの参照。公費の場合には、公費負担者組織Organizationリソースへの参照。

Comments

May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations.

保険会社の識別子や事業者の識別子(BIN番号)など、複数の識別子を提供してもよい。自己負担の場合は、複数の支払者および/または組織を提供してもよい。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
24. Coverage.class
Definition

A suite of underwriter specific classifiers.

保険事業者の分類子

Control0..*
TypeBackboneElement
Requirements

The codes provided on the health card which identify or confirm the specific policy for the insurer.

健康カードに記載されているコードで、保険者の特定の保険契約を識別または確認するもの。

Comments

For example may be used to identify a class of coverage or employer group, Policy, Plan.

例えば、保険の種類または雇用者グループ、保険契約、Planを識別するために使用することができる。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
25. Coverage.class.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
26. Coverage.class.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
27. Coverage.class.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser contentmodifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
28. Coverage.class.type
Definition

The type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan.

保険者固有のクラスラベルまたは番号、任意の名前が提供されている分類のタイプを表す。例えば、保険のクラスまたは雇用者グループ、保険契約、Planを識別するために使用することができる。

Control1..1
BindingThe codes SHALL be taken from CoverageClassCodes; other codes may be used where these codes are not suitable The policy classifications, eg. Group, Plan, Class, etc
TypeCodeableConcept
Requirements

The insurer issued label for a specific health card value.

保険者が発行した特定の健康カード番号のラベル。

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

すべての用語の使用がこの一般的なパターンに適合するわけではない。いくつかのケースでは、モデルはCodeableConceptを使用せず、Codingを直接使用し、テキスト、コーディング、翻訳、要素間の関係、および前後の調整を管理するための独自の構造を提供することが望ましい。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
29. Coverage.class.value
Definition

The alphanumeric string value associated with the insurer issued label.

保険者が発行したラベルに関連付けられた英数字の文字列値。

Control1..1
Typestring
Requirements

The insurer issued label and value are necessary to identify the specific policy.

保険者が発行したラベルと値は、特定の保険契約を識別するために必要なものである。

Comments

For example, the Group or Plan number.

例えば、グループ番号やプラン番号など。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
30. Coverage.class.name
Definition

A short description for the class.

保険種類の簡単な説明。

Control0..1
Typestring
Requirements

Used to provide a meaningful description in correspondence to the patient.

患者に対応するのに意味のある説明をするために使用する。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
31. Coverage.order
Definition

The order of applicability of this coverage relative to other coverages which are currently in force. Note, there may be gaps in the numbering and this does not imply primary, secondary etc. as the specific positioning of coverages depends upon the episode of care.

現在適用されている他の保障と比較して、この保障の適用可能性が高い順に記載されている。なお、ナンバリングにギャップがある場合があり、カバーの具体的な位置づけはケアのエピソードに依存するため、一次、二次などを意味するものではない。

Control0..1
TypepositiveInt
Requirements

Used in managing the coordination of benefits.

保険給付の調整管理に使用する。

【JP Core仕様】公費情報で本リソースを使用する場合で、複数の公費負担情報がある場合に、その適用順序番号を示す1,2,3...を設定する。

Comments

32 bit number; for values larger than this, use decimal

32 ビットの数値、これより大きい値の場合は 10 進数を使用する。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
32. Coverage.network
Definition

The insurer-specific identifier for the insurer-defined network of providers to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply.

保険者が定義したプロバイダの保険者定義ネットワークの保険者固有の識別子で、被保険者が「ネットワーク内」の料金でカバーされる治療を受けることができるが、そうでなければ「ネットワーク外」の条件が適用される。

Control0..1
Typestring
Requirements

Used in referral for treatment and in claims processing.

治療のための紹介や請求処理の際に使用する。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
33. Coverage.costToBeneficiary
Definition

A suite of codes indicating the cost category and associated amount which have been detailed in the policy and may have been included on the health card.

ポリシに詳細が記載されており、ヘルスカードに含まれている可能性のあるコストカテゴリと関連する金額を示す一連のコード。

Control0..*
TypeBackboneElement
Requirements

Required by providers to manage financial transaction with the patient.

事業者が患者との金銭的な取引を管理するために必要となる。

Alternate NamesCoPayDeductibleExceptions
Comments

For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.

例えば、患者の訪問時の自己負担額を知ることで、医療提供者は治療を行う前にその金額を回収することができる。

【JP Core仕様】公費の場合には自己負担率。判明している場合のみ設定する。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
34. Coverage.costToBeneficiary.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
35. Coverage.costToBeneficiary.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
36. Coverage.costToBeneficiary.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser contentmodifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
37. Coverage.costToBeneficiary.type
Definition

The category of patient centric costs associated with treatment.

治療に伴う患者中心の費用のカテゴリー。

Control0..1
BindingThe codes SHALL be taken from CoverageCopayTypeCodes; other codes may be used where these codes are not suitable The types of services to which patient copayments are specified
TypeCodeableConcept
Requirements

Needed to identify the category associated with the amount for the patient.

患者の金額に関連するカテゴリーを特定する必要がありました。

Comments

For example visit, specialist visits, emergency, inpatient care, etc.

例えば、訪問診療、専門医の訪問診療、救急診療、入院診療など。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
38. Coverage.costToBeneficiary.type.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
39. Coverage.costToBeneficiary.type.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
SlicingThis element introduces a set of slices on Coverage.costToBeneficiary.type.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
40. Coverage.costToBeneficiary.type.coding
Definition

A reference to a code defined by a terminology system.

Control0..*
TypeCoding
Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
41. Coverage.costToBeneficiary.type.coding.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
42. Coverage.costToBeneficiary.type.coding.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
SlicingThis element introduces a set of slices on Coverage.costToBeneficiary.type.coding.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
43. Coverage.costToBeneficiary.type.coding.system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Control0..1
Typeuri
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

保険や公費における自己負担率の種別を識別するコード体系のコード。 "http://terminology.hl7.org/CodeSystem/coverage-copay-type"

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
44. Coverage.costToBeneficiary.type.coding.version
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

NoteThis is a business versionId, not a resource version id (see discussion)
Control0..1
Typestring
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
45. Coverage.costToBeneficiary.type.coding.code
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Control0..1
Typecode
Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

自己負担率を表すコード "copaypct"

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
46. Coverage.costToBeneficiary.type.coding.display
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Control0..1
Typestring
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
47. Coverage.costToBeneficiary.type.coding.userSelected
Definition

Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

Control0..1
Typeboolean
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
48. Coverage.costToBeneficiary.type.text
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Control0..1
Typestring
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
49. Coverage.costToBeneficiary.value[x]
Definition

The amount due from the patient for the cost category.

費用区分の患者からの支払額。

Control1..1
TypeChoice of: Quantity(SimpleQuantity), Money
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Needed to identify the amount for the patient associated with the category.

カテゴリーに関連する患者の支払い金額を特定する必要がありました。

Comments

Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.

金額は、サービス/製品のコストに対する割合で表現される場合と、通貨の固定額で表現される場合がある。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
50. Coverage.costToBeneficiary.exception
Definition

A suite of codes indicating exceptions or reductions to patient costs and their effective periods.

患者費用の例外または削減を示すコードとその有効期間を示すコード群。

Control0..*
TypeBackboneElement
Requirements

Required by providers to manage financial transaction with the patient.

事業者が患者との金銭的な取引を管理するために必要となる。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
51. Coverage.costToBeneficiary.exception.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
52. Coverage.costToBeneficiary.exception.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
53. Coverage.costToBeneficiary.exception.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser contentmodifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
54. Coverage.costToBeneficiary.exception.type
Definition

The code for the specific exception.

特定の例外のコード。

Control1..1
BindingFor example codes, see ExampleCoverageFinancialExceptionCodes The types of exceptions from the part or full value of financial obligations such as copays
TypeCodeableConcept
Requirements

Needed to identify the exception associated with the amount for the patient.

患者の金額に関連する例外を特定する必要があった。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
55. Coverage.costToBeneficiary.exception.period
Definition

The timeframe during when the exception is in force.

例外が発生している間の時間枠。

Control0..1
TypePeriod
Requirements

Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs.

患者の費用を正しく計算するための例外の適用時期を特定する必要があった。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
56. Coverage.subrogation
Definition

When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs.

subrogation=trueの場合、この保険インスタンスは裁定のためではなく、保険者に費用回収のための詳細を提供するために含まれている。 (subrogation=代位、subrogation payment=代位納付)

Control0..1
Typeboolean
Requirements

See definition for when to be used.

使用時期については定義を参照すること。

Comments

Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.

一般的に、自動車保険や労災保険では、医療費支払い者が事故請求に対して回収できるように、subrogation=true というフラグが立てられている。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
57. Coverage.contract
Definition

The policy(s) which constitute this insurance coverage.

この保険の適用範囲を構成するポリシ。

Control0..*
TypeReference(Contract))
Requirements

To reference the legally binding contract between the policy holder and the insurer.

契約者と保険者との間の法的拘束力のある契約を参照するため。

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

参照は、実際のFHIRリソースへの参照である必要があり、解決可能(内容に到達可能)である必要がある(アクセス制御、一時的な使用不可などを考慮に入れる)。解決は、URLから取得するか、リソースタイプによって該当する場合は、絶対参照を正規URLとして扱い、ローカルレジストリ/リポジトリで検索することによって行うことができる。

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))