Current Build
Financial Management Work GroupMaturity Level: 2 Trial UseSecurity Category: Patient Compartments: Patient, RelatedPerson

Detailed Descriptions for the elements in the Coverage resource.

Coverage
Element IdCoverage
Definition

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

Cardinality0..*
TypeDomainResource
Requirements

Coverage provides a link between covered parties (patients) and the payors of their healthcare costs (both insurance and self-pay).

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.identifier
Element IdCoverage.identifier
Definition

A unique identifier assigned to this coverage.

NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
TypeIdentifier
Requirements

Allows coverages to be distinguished and referenced.

Summarytrue
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.dependant.

Coverage.status
Element IdCoverage.status
Definition

The status of the resource instance.

Cardinality1..1
Terminology BindingFinancial Resource Status Codes (Required)
Typecode
Is Modifiertrue (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
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'.

Summarytrue
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.

Coverage.type
Element IdCoverage.type
Definition

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

Cardinality0..1
Terminology BindingCoverage Type and Self-Pay Codes (Preferred)
TypeCodeableConcept
Requirements

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

Summarytrue
Coverage.policyHolder
Element IdCoverage.policyHolder
Definition

The party who 'owns' the insurance policy.

Cardinality0..1
TypeReference(Patient | RelatedPerson | Organization)
PatternsReference(Patient,RelatedPerson,Organization): Common patterns = Participant, ParticipantContactable
Requirements

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

Summarytrue
Comments

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

Coverage.subscriber
Element IdCoverage.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.

Cardinality0..1
TypeReference(Patient | RelatedPerson)
PatternsReference(Patient,RelatedPerson): Common patterns = Participant, ParticipantContactable, ParticipantLiving
Requirements

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

Summarytrue
Comments

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

Coverage.subscriberId
Element IdCoverage.subscriberId
Definition

The insurer assigned ID for the Subscriber.

Cardinality0..1
Typestring
Requirements

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

Summarytrue
Coverage.beneficiary
Element IdCoverage.beneficiary
Definition

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

Cardinality1..1
TypeReference(Patient)
Requirements

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

Summarytrue
Coverage.dependent
Element IdCoverage.dependent
Definition

A unique identifier for a dependent under the coverage.

Cardinality0..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.

Summarytrue
Comments

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

Coverage.relationship
Element IdCoverage.relationship
Definition

The relationship of beneficiary (patient) to the subscriber.

Cardinality0..1
Terminology BindingSubscriberPolicyholder Relationship Codes (Extensible)
TypeCodeableConcept
Requirements

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

Comments

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

Coverage.period
Element IdCoverage.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.

Cardinality0..1
TypePeriod
Requirements

Some insurers require the submission of the coverage term.

Summarytrue
Coverage.payor
Element IdCoverage.payor
Definition

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

Cardinality1..*
TypeReference(Organization | Patient | RelatedPerson)
PatternsReference(Organization,Patient,RelatedPerson): Common patterns = Participant, ParticipantContactable
Requirements

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

Summarytrue
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.

Coverage.class
Element IdCoverage.class
Definition

A suite of underwriter specific classifiers.

Cardinality0..*
Requirements

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

Comments

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

Coverage.class.type
Element IdCoverage.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.

Cardinality1..1
Terminology BindingCoverage Class Codes (Extensible)
TypeCodeableConcept
Requirements

The insurer issued label for a specific health card value.

Summarytrue
Coverage.class.value
Element IdCoverage.class.value
Definition

The alphanumeric string value associated with the insurer issued label.

Cardinality1..1
Typestring
Requirements

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

Summarytrue
Comments

For example, the Group or Plan number.

Coverage.class.name
Element IdCoverage.class.name
Definition

A short description for the class.

Cardinality0..1
Typestring
Requirements

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

Summarytrue
Coverage.order
Element IdCoverage.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.

Cardinality0..1
TypepositiveInt
Requirements

Used in managing the coordination of benefits.

Summarytrue
Coverage.network
Element IdCoverage.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.

Cardinality0..1
Typestring
Requirements

Used in referral for treatment and in claims processing.

Summarytrue
Coverage.costToBeneficiary
Element IdCoverage.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.

Cardinality0..*
Requirements

Required by providers to manage financial transaction with the patient.

Alternate NamesCoPay; Deductible; Exceptions
Comments

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

Coverage.costToBeneficiary.type
Element IdCoverage.costToBeneficiary.type
Definition

The category of patient centric costs associated with treatment.

Cardinality0..1
Terminology BindingCoverage Copay Type Codes (Extensible)
TypeCodeableConcept
Requirements

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

Summarytrue
Comments

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

Coverage.costToBeneficiary.value[x]
Element IdCoverage.costToBeneficiary.value[x]
Definition

The amount due from the patient for the cost category.

Cardinality1..1
TypeSimpleQuantity|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.

Summarytrue
Comments

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

Coverage.costToBeneficiary.exception
Element IdCoverage.costToBeneficiary.exception
Definition

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

Cardinality0..*
Requirements

Required by providers to manage financial transaction with the patient.

Coverage.costToBeneficiary.exception.type
Element IdCoverage.costToBeneficiary.exception.type
Definition

The code for the specific exception.

Cardinality1..1
Terminology BindingExample Coverage Financial Exception Codes (Example)
TypeCodeableConcept
Requirements

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

Summarytrue
Coverage.costToBeneficiary.exception.period
Element IdCoverage.costToBeneficiary.exception.period
Definition

The timeframe during when the exception is in force.

Cardinality0..1
TypePeriod
Requirements

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

Summarytrue
Coverage.subrogation
Element IdCoverage.subrogation
Definition

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

Cardinality0..1
Typeboolean
Requirements

See definition for when to be used.

Comments

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

Coverage.contract
Element IdCoverage.contract
Definition

The policy(s) which constitute this insurance coverage.

Cardinality0..*
TypeReference(Contract)
Requirements

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