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Financial Management icon 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.

Short DisplayInsurance or medical plan or a payment agreement
Cardinality0..*
TypeDomainResource
Requirements

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

Summaryfalse
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

The identifier of the coverage as issued by the insurer.

Short DisplayBusiness identifier(s) for 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. Note that not all insurers issue unique member IDs therefore searches may result in multiple responses.

Coverage.status
Element IdCoverage.status
Definition

The status of the resource instance.

Short Displayactive | cancelled | draft | entered-in-error
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.kind
Element IdCoverage.kind
Definition

The nature of the coverage be it insurance, or cash payment such as self-pay.

Short Displayinsurance | self-pay | other
Cardinality1..1
Terminology BindingKind (Required)
Typecode
Requirements

This is used to implement conformance on other elements.

Summarytrue
Coverage.paymentBy
Element IdCoverage.paymentBy
Definition

Link to the paying party and optionally what specifically they will be responsible to pay.

Short DisplaySelf-pay parties and responsibility
Cardinality0..*
Summaryfalse
Coverage.paymentBy.party
Element IdCoverage.paymentBy.party
Definition

The list of parties providing non-insurance payment for the treatment costs.

Short DisplayParties performing self-payment
Cardinality1..1
TypeReference(Patient | RelatedPerson | Organization)
Summarytrue
Coverage.paymentBy.responsibility
Element IdCoverage.paymentBy.responsibility
Definition

Description of the financial responsibility.

Short DisplayParty's responsibility
Cardinality0..1
Typestring
Summarytrue
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.

Short DisplayCoverage category such as medical or accident
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.

Short DisplayOwner of the policy
Cardinality0..1
TypeReference(Patient | RelatedPerson | Organization)
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.

Short DisplaySubscriber to the policy
Cardinality0..1
TypeReference(Patient | RelatedPerson)
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.

Short DisplayID assigned to the subscriber
Cardinality0..*
TypeIdentifier
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.

Short DisplayPlan beneficiary
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 designator for a dependent under the coverage.

Short DisplayDependent number
Cardinality0..1
Typestring
Requirements

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

Summarytrue
Comments

Sometimes 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.

Short DisplayBeneficiary relationship to the subscriber
Cardinality0..1
Terminology BindingSubscriberPolicyholder Relationship Codes (Extensible)
TypeCodeableConcept
Requirements

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

Summaryfalse
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.

Short DisplayCoverage start and end dates
Cardinality0..1
TypePeriod
Requirements

Some insurers require the submission of the coverage term.

Summarytrue
Coverage.insurer
Element IdCoverage.insurer
Definition

The program or plan underwriter, payor, insurance company.

Short DisplayIssuer of the policy
Cardinality0..1
TypeReference(Organization)
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).

Coverage.class
Element IdCoverage.class
Definition

A suite of underwriter specific classifiers.

Short DisplayAdditional coverage classifications
Cardinality0..*
Requirements

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

Summaryfalse
Comments

For example, class may be used to identify a class of coverage or employer group, policy, or 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, type may be used to identify a class of coverage or employer group, policy, or plan.

Short DisplayType of class such as 'group' or '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 identifier associated with the insurer issued label.

Short DisplayValue associated with the type
Cardinality1..1
TypeIdentifier
Requirements

The insurer issued label and identifier are necessary to identify the specific policy, group, etc..

Summarytrue
Comments

For example, the Group or Plan number.

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

A short description for the class.

Short DisplayHuman readable description of the type and value
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. For example; a patient might have (0) auto insurance (1) their own health insurance and (2) spouse's health insurance. When claiming for treatments which were not the result of an auto accident then only coverages (1) and (2) above would be applicatble and would apply in the order specified in parenthesis.

Short DisplayRelative order of the coverage
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.

Short DisplayInsurer network
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.

Short DisplayPatient payments for services/products
Cardinality0..*
Requirements

Required by providers to manage financial transaction with the patient.

Alternate NamesCoPay; Deductible; Exceptions
Summaryfalse
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.

Short DisplayCost category
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.category
Element IdCoverage.costToBeneficiary.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Short DisplayBenefit classification
Cardinality0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
Requirements

Needed to convey the category of service or product for which eligibility is sought.

Summaryfalse
Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Coverage.costToBeneficiary.network
Element IdCoverage.costToBeneficiary.network
Definition

Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.

Short DisplayIn or out of network
Cardinality0..1
Terminology BindingNetwork Type Codes (Example)
TypeCodeableConcept
Requirements

Needed as in or out of network providers are treated differently under the coverage.

Summaryfalse
Coverage.costToBeneficiary.unit
Element IdCoverage.costToBeneficiary.unit
Definition

Indicates if the benefits apply to an individual or to the family.

Short DisplayIndividual or family
Cardinality0..1
Terminology BindingUnit Type Codes (Example)
TypeCodeableConcept
Requirements

Needed for the understanding of the benefits.

Summaryfalse
Coverage.costToBeneficiary.term
Element IdCoverage.costToBeneficiary.term
Definition

The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.

Short DisplayAnnual or lifetime
Cardinality0..1
Terminology BindingBenefit Term Codes (Example)
TypeCodeableConcept
Requirements

Needed for the understanding of the benefits.

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

The amount due from the patient for the cost category.

Short DisplayThe amount or percentage due from the beneficiary
Cardinality0..1
TypeSimpleQuantity|Money
[x] NoteSee Choice of Datatypes 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.

Short DisplayExceptions for patient payments
Cardinality0..*
Requirements

Required by providers to manage financial transaction with the patient.

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

The code for the specific exception.

Short DisplayException category
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 the exception is in force.

Short DisplayThe effective period of the exception
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.

Short DisplayReimbursement to insurer
Cardinality0..1
Typeboolean
Requirements

See definition for when to be used.

Summaryfalse
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.

Short DisplayContract details
Cardinality0..*
TypeReference(Contract)
Requirements

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

Summaryfalse
Coverage.insurancePlan
Element IdCoverage.insurancePlan
Definition

The insurance plan details, benefits and costs, which constitute this insurance coverage.

Short DisplayInsurance plan details
Cardinality0..1
TypeReference(InsurancePlan)
Requirements

To associate the plan benefits and costs with the coverage which is an instance of that plan.

Summaryfalse