Release 5

This page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

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.

13.1.3 References to this Resource

13.1.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage TUDomainResourceInsurance or medical plan or a payment agreement

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ0..*IdentifierBusiness identifier(s) for this coverage

... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes (Required)
... kind Σ1..1codeinsurance | self-pay | other
Binding: Kind (Required)
.... party Σ1..1Reference(Patient | RelatedPerson | Organization)Parties performing self-payment
.... responsibility Σ0..1stringParty's responsibility
... type Σ0..1CodeableConceptCoverage category such as medical or accident
Binding: Coverage Type and Self-Pay Codes (Preferred)
... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId Σ0..*IdentifierID assigned to the subscriber

... beneficiary Σ1..1Reference(Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberPolicyholder Relationship Codes (Extensible)
... period Σ0..1PeriodCoverage start and end dates
... insurer Σ0..1Reference(Organization)Issuer of the policy
... class 0..*BackboneElementAdditional coverage classifications

.... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: Coverage Class Codes (Extensible)
.... value Σ1..1IdentifierValue associated with the type
.... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products

.... type Σ0..1CodeableConceptCost category
Binding: Coverage Copay Type Codes (Extensible)
.... category 0..1CodeableConceptBenefit classification
Binding: Benefit Category Codes (Example)
.... network 0..1CodeableConceptIn or out of network
Binding: Network Type Codes (Example)
.... unit 0..1CodeableConceptIndividual or family
Binding: Unit Type Codes (Example)
.... term 0..1CodeableConceptAnnual or lifetime
Binding: Benefit Term Codes (Example)
.... value[x] Σ0..1The amount or percentage due from the beneficiary
..... valueQuantitySimpleQuantity
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments

..... type Σ1..1CodeableConceptException category
Binding: Example Coverage Financial Exception Codes (Example)
..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

... insurancePlan 0..1Reference(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

PathValueSetTypeDocumentation
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.

NameTypeDescriptionExpressionIn Common
beneficiaryreferenceCovered partyCoverage.beneficiary
(Patient)
class-typetokenCoverage class (e.g. plan, group)Coverage.class.type
class-valuetokenValue of the class (e.g. Plan number, group number)Coverage.class.value
dependentstringDependent numberCoverage.dependent
identifiertokenThe primary identifier of the insured and the coverageCoverage.identifier65 Resources
insurerreferenceThe identity of the insurerCoverage.insurer
(Organization)
patientreferenceRetrieve coverages for a patientCoverage.beneficiary
(Patient)		66 Resources
paymentby-partyreferenceParties who will pay for servicesCoverage.paymentBy.party
(Organization, Patient, RelatedPerson)
policy-holderreferenceReference to the policyholderCoverage.policyHolder
(Organization, Patient, RelatedPerson)
statustokenThe status of the CoverageCoverage.status
subscriberreferenceReference to the subscriberCoverage.subscriber
(Patient, RelatedPerson)
subscriberidtokenIdentifier of the subscriberCoverage.subscriberId
typetokenThe kind of coverage (health plan, auto, Workers Compensation)Coverage.type11 Resources
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