Coverage Profile

Canonical	../StructureDefinition/nexus-emr-core-coverage
Status	draft (experimental) · 1.26.0
Base	Coverage (constraint)
Source	FSH · JSON

Nexus EMR profile for Coverage -- the payor context for billing and the demo dataset. First pass: the Ontario-GP shape (public plan keyed by the patient's health-card number, payor as a logical Organization reference). Private/extended plans and coordination of benefits are deliberately unmodelled. Closed to SMART apps pending an exposure decision.

Overview

Overview

The Nexus EMR Core Coverage profile carries the payor context a billing surface needs: which plan pays. Invoices and fee lines can say what was billed, but without Coverage they cannot say who is being billed under which plan, and the chart has no insurance context to display. The clinical Task profile also references Coverage through Task.insurance, and this profile is what that reference resolves to.

The first pass models the Ontario general-practice shape and nothing wider: one public plan, identified by the patient's health-card number, with the payor expressed as a logical Organization reference. Private and extended plans (class, network, costToBeneficiary), coordination of benefits (order), and the out-of-province posture are deliberately unmodelled. The profile is closed to SMART apps pending an exposure decision.

subscriberId is the payor's key, not a second patient identifier

subscriberId (0..1) is the identifier the plan knows the covered person by. For Ontario's public plan that is the health-card number, which means the same digits also appear on Patient.identifier under this IG's provincial-identifier machinery. That duplication is intentional and the two are not interchangeable: subscriberId is the value the payor bills against, and it does not replace or override the patient's identifier slice. A consumer resolving patient identity should read Patient.identifier; a consumer assembling a claim should read subscriberId.

beneficiary is 1..1 and only Reference(NexusEmrCorePatient). status is 1..1 (active | cancelled | draft | entered-in-error).

payor is normally a logical reference

payor is 1..*. Provincial payors are not resources this platform maintains, so the expected first-pass shape is a logical reference: Reference.identifier naming the plan authority and Reference.display carrying the human-readable name, with no resolvable Reference.reference. Consumers must not assume a payor reference can be dereferenced to an Organization resource.

type is 0..1 and its vocabulary is deliberately left open in this pass -- Ontario's public plan rides as type.text plus the payor identifier. A plan-type value set is deferred until a second plan actually flows, so current type values are not a contract and code should not branch on them.

Coverage has no clinical effective date

This profile explicitly declares that it has no effective date, which is different from declaring nothing. period (0..1) is administrative validity: when the plan covers the beneficiary. It is not a clinical date, and a consumer must not use it to place the Coverage on a chart timeline or to feed a recency window -- doing so would let an insurance record re-anchor the chart's reference day. Patient and Organization are pinned empty for the same reason.

See Coverage/nexus-emr-coverage-example for a worked instance.