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Resource Profile: Oncology Kenya Coverage

Official URL: http://example.org/StructureDefinition/oncology-kenya-coverage Version: 0.1.0
Draft as of 2025-06-24 Computable Name: OncologyKenyaCoverage

Defines insurance and reimbursement details under SHA in Kenya, ensuring financial tracking and integration with NCCP Data Systems.

Usages:

  • This Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* Coverage Insurance or medical plan or a payment agreement
... type 0..1 CodeableConcept Coverage category such as medical or accident
Binding: http://terminology.health.go.ke/ValueSet/coverage-type-kenya (required)
... policyHolder S 1..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
... subscriber S 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
... beneficiary S 1..1 Reference(Patient) Plan beneficiary
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
... period
.... start S 1..1 dateTime Starting time with inclusive boundary
.... end S 0..1 dateTime End time with inclusive boundary, if not ongoing
... payor S 1..* Reference(Organization | Patient | RelatedPerson) Issuer of the policy
... class
.... type S 1..1 CodeableConcept Type of class such as 'group' or 'plan'
.... value S 1..1 string Value associated with the type
... costToBeneficiary S 0..* BackboneElement Patient payments for services/products

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Coverage.typerequiredhttp://terminology.health.go.ke/ValueSet/coverage-type-kenya
http://terminology.health.go.ke/ValueSet/coverage-type-kenya
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* Coverage Insurance or medical plan or a payment agreement
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... policyHolder SΣ 1..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
... subscriber SΣ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
... subscriberId SΣ 0..1 string ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(Patient) Plan beneficiary
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
... period Σ 0..1 Period Coverage start and end dates
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
.... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... payor SΣ 1..* Reference(Organization | Patient | RelatedPerson) Issuer of the policy
... class 0..* BackboneElement Additional coverage classifications
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type SΣ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
.... value SΣ 1..1 string Value associated with the type
... costToBeneficiary S 0..* BackboneElement Patient payments for services/products
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... value[x] Σ 1..1 The amount or percentage due from the beneficiary
..... valueQuantity Quantity(SimpleQuantity)
..... valueMoney Money

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From the FHIR Standard
Coverage.typerequiredhttp://terminology.health.go.ke/ValueSet/coverage-type-kenya
http://terminology.health.go.ke/ValueSet/coverage-type-kenya
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
From the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageIf 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-4errorCoverageIf 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-5errorCoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* Coverage Insurance or medical plan or a payment agreement
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for the coverage
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type Σ 0..1 CodeableConcept Coverage category such as medical or accident
Binding: http://terminology.health.go.ke/ValueSet/coverage-type-kenya (required)
... policyHolder SΣ 1..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
... subscriber SΣ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
... subscriberId SΣ 0..1 string ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(Patient) Plan beneficiary
... dependent Σ 0..1 string Dependent number
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
... period Σ 0..1 Period Coverage start and end dates
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
.... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... payor SΣ 1..* Reference(Organization | Patient | RelatedPerson) Issuer of the policy
... class 0..* BackboneElement Additional coverage classifications
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type SΣ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
.... value SΣ 1..1 string Value associated with the type
.... name Σ 0..1 string Human readable description of the type and value
... order Σ 0..1 positiveInt Relative order of the coverage
... network Σ 0..1 string Insurer network
... costToBeneficiary S 0..* BackboneElement Patient payments for services/products
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type Σ 0..1 CodeableConcept Cost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
.... value[x] Σ 1..1 The amount or percentage due from the beneficiary
..... valueQuantity Quantity(SimpleQuantity)
..... valueMoney Money
.... exception 0..* BackboneElement Exceptions for patient payments
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Exception category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
..... period Σ 0..1 Period The effective period of the exception
... subrogation 0..1 boolean Reimbursement to insurer
... contract 0..* Reference(Contract) Contract details

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Coverage.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From the FHIR Standard
Coverage.typerequiredhttp://terminology.health.go.ke/ValueSet/coverage-type-kenya
http://terminology.health.go.ke/ValueSet/coverage-type-kenya
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
From the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
From the FHIR Standard
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
http://hl7.org/fhir/ValueSet/coverage-copay-type
From the FHIR Standard
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
http://hl7.org/fhir/ValueSet/coverage-financial-exception
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageIf 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-4errorCoverageIf 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-5errorCoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Coverage

Summary

Mandatory: 2 elements(1 nested mandatory element)
Must-Support: 11 elements

Differential View

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* Coverage Insurance or medical plan or a payment agreement
... type 0..1 CodeableConcept Coverage category such as medical or accident
Binding: http://terminology.health.go.ke/ValueSet/coverage-type-kenya (required)
... policyHolder S 1..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
... subscriber S 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
... beneficiary S 1..1 Reference(Patient) Plan beneficiary
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
... period
.... start S 1..1 dateTime Starting time with inclusive boundary
.... end S 0..1 dateTime End time with inclusive boundary, if not ongoing
... payor S 1..* Reference(Organization | Patient | RelatedPerson) Issuer of the policy
... class
.... type S 1..1 CodeableConcept Type of class such as 'group' or 'plan'
.... value S 1..1 string Value associated with the type
... costToBeneficiary S 0..* BackboneElement Patient payments for services/products

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Coverage.typerequiredhttp://terminology.health.go.ke/ValueSet/coverage-type-kenya
http://terminology.health.go.ke/ValueSet/coverage-type-kenya

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* Coverage Insurance or medical plan or a payment agreement
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... policyHolder SΣ 1..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
... subscriber SΣ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
... subscriberId SΣ 0..1 string ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(Patient) Plan beneficiary
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
... period Σ 0..1 Period Coverage start and end dates
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
.... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... payor SΣ 1..* Reference(Organization | Patient | RelatedPerson) Issuer of the policy
... class 0..* BackboneElement Additional coverage classifications
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type SΣ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
.... value SΣ 1..1 string Value associated with the type
... costToBeneficiary S 0..* BackboneElement Patient payments for services/products
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... value[x] Σ 1..1 The amount or percentage due from the beneficiary
..... valueQuantity Quantity(SimpleQuantity)
..... valueMoney Money

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From the FHIR Standard
Coverage.typerequiredhttp://terminology.health.go.ke/ValueSet/coverage-type-kenya
http://terminology.health.go.ke/ValueSet/coverage-type-kenya
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
From the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageIf 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-4errorCoverageIf 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-5errorCoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* Coverage Insurance or medical plan or a payment agreement
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for the coverage
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type Σ 0..1 CodeableConcept Coverage category such as medical or accident
Binding: http://terminology.health.go.ke/ValueSet/coverage-type-kenya (required)
... policyHolder SΣ 1..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
... subscriber SΣ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
... subscriberId SΣ 0..1 string ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(Patient) Plan beneficiary
... dependent Σ 0..1 string Dependent number
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
... period Σ 0..1 Period Coverage start and end dates
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
.... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... payor SΣ 1..* Reference(Organization | Patient | RelatedPerson) Issuer of the policy
... class 0..* BackboneElement Additional coverage classifications
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type SΣ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
.... value SΣ 1..1 string Value associated with the type
.... name Σ 0..1 string Human readable description of the type and value
... order Σ 0..1 positiveInt Relative order of the coverage
... network Σ 0..1 string Insurer network
... costToBeneficiary S 0..* BackboneElement Patient payments for services/products
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type Σ 0..1 CodeableConcept Cost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
.... value[x] Σ 1..1 The amount or percentage due from the beneficiary
..... valueQuantity Quantity(SimpleQuantity)
..... valueMoney Money
.... exception 0..* BackboneElement Exceptions for patient payments
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Exception category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
..... period Σ 0..1 Period The effective period of the exception
... subrogation 0..1 boolean Reimbursement to insurer
... contract 0..* Reference(Contract) Contract details

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Coverage.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From the FHIR Standard
Coverage.typerequiredhttp://terminology.health.go.ke/ValueSet/coverage-type-kenya
http://terminology.health.go.ke/ValueSet/coverage-type-kenya
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
From the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
From the FHIR Standard
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
http://hl7.org/fhir/ValueSet/coverage-copay-type
From the FHIR Standard
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
http://hl7.org/fhir/ValueSet/coverage-financial-exception
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageIf 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-4errorCoverageIf 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-5errorCoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Coverage

Summary

Mandatory: 2 elements(1 nested mandatory element)
Must-Support: 11 elements

 

Other representations of profile: CSV, Excel, Schematron