FHIR CI-Build

This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
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13.1 Resource Coverage - Content

Financial Management icon Work GroupMaturity Level: 4 Trial UseSecurity Category: Patient Compartments: Patient, RelatedPerson

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

13.1.1 Scope and Usage

The Coverage resource is intended to provide the high-level identifiers and descriptors of an insurance plan, typically the information which would appear on an insurance card, which may be used to pay, in part or in whole, for the provision of health care products and services.

This resource may also be used to register 'SelfPay' where an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs. Selfpay should not be confused with being a guarantor of the patient's account.

The Coverage resource is a "event" resource from a FHIR workflow perspective - see Workflow Request.

13.1.2 Boundaries and Relationships

The eClaim domain includes a number of related insurance resources

Coverage The Coverage resource is intended to provide the high-level identifiers and descriptors of a specific insurance plan for a specific individual - essentially the insurance card information. This may alternately provide the individual or organization, selfpay, which will pay for products and services rendered.
Contract A Contract resource holds the references to parties who have entered into an agreement of some type, the parties who may sign or witness such an agreement, descriptors of the type of agreement and even the actual text or executable copy of the agreement. The agreement may be of a variety of types including service contracts, insurance contracts, directives, etc. The contract may be either definitional or actual instances.
InsurancePlan The InsurancePlan resource holds the definition of an insurance plan which an insurer may offer to potential clients through insurance brokers or an online insurance marketplace. This is only the plan definition and does not contain or reference a list of individuals who have purchased the plan.
TODO: Do we need to reference the InsuranceProduct here instead?

13.1.3 References to this Resource

13.1.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage TU DomainResource Insurance or medical plan or a payment agreement

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ 0..* Identifier Business identifier(s) for this coverage

... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes (Required)
... kind Σ 1..1 code insurance | self-pay | other
Binding: Kind (Required)
.... party Σ 1..1 Reference(Patient | RelatedPerson | Organization) Parties performing self-payment
.... responsibility Σ 0..1 string Party's responsibility
... type Σ 0..1 CodeableConcept Coverage category such as medical or accident
Binding: Coverage Type and Self-Pay Codes (Preferred)
... policyHolder Σ 0..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
... subscriber Σ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
... subscriberId Σ 0..* Identifier ID assigned to the subscriber

... beneficiary Σ 1..1 Reference(Patient) Plan beneficiary
... dependent Σ 0..1 string Dependent number
... relationship 0..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberPolicyholder Relationship Codes (Extensible)
... period Σ 0..1 Period Coverage start and end dates
... insurer Σ 0..1 Reference(Organization) Issuer of the policy
... class 0..* BackboneElement Additional coverage classifications

.... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: Coverage Class Codes (Extensible)
.... value Σ 1..1 Identifier 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 0..* BackboneElement Patient payments for services/products

.... type Σ 0..1 CodeableConcept Cost category
Binding: Coverage Copay Type Codes (Extensible)
.... category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes (Example)
.... network 0..1 CodeableConcept In or out of network
Binding: Network Type Codes (Example)
.... unit 0..1 CodeableConcept Individual or family
Binding: Unit Type Codes (Example)
.... term 0..1 CodeableConcept Annual or lifetime
Binding: Benefit Term Codes (Example)
.... value[x] Σ 0..1 The amount or percentage due from the beneficiary
..... valueQuantity SimpleQuantity
..... valueMoney Money
.... exception 0..* BackboneElement Exceptions for patient payments

..... type Σ 1..1 CodeableConcept Exception category
Binding: Example Coverage Financial Exception Codes (Example)
..... period Σ 0..1 Period The effective period of the exception
... subrogation 0..1 boolean Reimbursement to insurer
... contract 0..* Reference(Contract) Contract details

... insurancePlan 0..1 Reference(InsurancePlan) Insurance plan details

doco Documentation for this format icon

See the Extensions for this resource

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

13.1.4.1 Terminology Bindings

Path ValueSet Type Documentation
Coverage.status FinancialResourceStatusCodes Required

This value set includes Status codes.
Coverage.kind Kind Required

The kind of coverage: insurance, selfpay or other.
Coverage.type CoverageTypeAndSelfPayCodes Preferred

This value set includes Coverage Type codes.
Coverage.relationship SubscriberRelationshipCodes (a valid code from SubscriberPolicyholder Relationship Codes icon) Extensible

This value set includes codes for the relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
Coverage.class.type CoverageClassCodes Extensible

This value set includes Coverage Class codes.
Coverage.costToBeneficiary.type CoverageCopayTypeCodes Extensible

This value set includes sample Coverage Copayment Type codes.
Coverage.costToBeneficiary.category BenefitCategoryCodes Example

This value set includes examples of Benefit Category codes.
Coverage.costToBeneficiary.network NetworkTypeCodes Example

This value set includes a smattering of Network type codes.
Coverage.costToBeneficiary.unit UnitTypeCodes Example

This value set includes a smattering of Unit type codes.
Coverage.costToBeneficiary.term BenefitTermCodes Example

This value set includes a smattering of Benefit Term codes.
Coverage.costToBeneficiary.exception.type ExampleCoverageFinancialExceptionCodes Example

This value set includes Example Coverage Financial Exception Codes.

13.1.5 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
beneficiary reference Covered party Coverage.beneficiary
(Patient)
class-type token Coverage class (e.g. plan, group) Coverage.class.type
class-value token Value of the class (e.g. Plan number, group number) Coverage.class.value
dependent string Dependent number Coverage.dependent
identifier token The primary identifier of the insured and the coverage Coverage.identifier 65 Resources
insurer reference The identity of the insurer Coverage.insurer
(Organization)
patient reference Retrieve coverages for a patient Coverage.beneficiary
(Patient)		 65 Resources
paymentby-party reference Parties who will pay for services Coverage.paymentBy.party
(Organization, Patient, RelatedPerson)
policy-holder reference Reference to the policyholder Coverage.policyHolder
(Organization, Patient, RelatedPerson)
status token The status of the Coverage Coverage.status
subscriber reference Reference to the subscriber Coverage.subscriber
(Patient, RelatedPerson)
subscriberid token Identifier of the subscriber Coverage.subscriberId
type token The kind of coverage (health plan, auto, Workers Compensation) Coverage.type 11 Resources