FHIR Release 3 (STU) CI-Build

This page is part of the FHIR Specification (v3.0.2: STU 3). The current version which supercedes this version is 5.0.0 . For a full list Continuous Integration Build of available versions, see FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions icon . Page versions: R5 R4B R4 R3 R2

13.1 Resource Coverage - Content

Responsible Owner: Financial Management icon Work Group   Normative Maturity Level : 2   Trial Use Security 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 high-level identifiers and potentially descriptors of an insurance plan plan, typically the information which would appear on an insurance card, which may be used to pay for, 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 referenced by 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

13.1.2 13.1.4 Resource Content

Structure

The primary 0..1 Type of coverage 0..1 0..1 Identifier for 0..1 0..1 Display text for an identifier for An identifier for the subsection Display text for the subsection Σ 0..1 Display text Σ Σ Σ string Σ Σ 0..1 0..1 Relative order Σ
Name Flags Card. Type Description & Constraints      Filter: Filters doco
. . Coverage N 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 ID

. . . status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes ( Required )
. . type . statusReason Σ 0..1 string Reason for status change
. . . paymentBy C 0..* BackboneElement Self-pay parties and responsibility

.... 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..* string Identifier ID assigned to the Subscriber subscriber

. . . beneficiary Σ 1..1 Reference ( Patient ) Plan Beneficiary beneficiary
. . relationship . dependent Σ 0..1 string Dependent number
... relationship 0..1 CodeableConcept Beneficiary relationship to the Subscriber subscriber
Policyholder Binding: SubscriberPolicyholder Relationship Codes ( Example Extensible )
. . . period Σ 0..1 Period Coverage start and end dates
. . . payor insurer Σ C 0..* 0..1 Reference ( Organization | Patient | RelatedPerson ) Issuer of the plan or agreement issuer policy
. . grouping . class 0..1 0..* BackboneElement Additional coverage classifications

. . . group . type Σ 1..1 string CodeableConcept Type of class such as 'group' or 'plan'
Binding: Coverage Class Codes ( Extensible )
An identifier for the group
. . . groupDisplay . value Σ 1..1 string Identifier Value associated with the group type
. . . . subGroup name Σ 0..1 string Human readable description of the group type and value
. . subGroupDisplay . order Σ 0..1 string positiveInt Relative order of the group coverage
. . . plan network Σ 0..1 string Insurer network
An identifier for the plan
. . planDisplay . costToBeneficiary 0..* string BackboneElement Patient payments for the plan services/products

. . . subPlan . type Σ 0..1 string CodeableConcept Cost category
Binding: Coverage Copay Type Codes ( Extensible )
An identifier for the subsection of the plan
. . . subPlanDisplay . category 0..1 string CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
Display text for the subsection of the plan
. . . class . network 0..1 string CodeableConcept In or out of network
Binding: Network Type Codes ( Preferred )
An identifier for the class
. . . classDisplay . unit 0..1 string CodeableConcept Individual or family
Binding: Unit Type Codes ( Preferred )
Display text for the class
. . . subClass . term 0..1 Σ CodeableConcept Annual or lifetime
Binding: Benefit Term Codes ( Preferred )
0..1
. . . . value[x] An identifier for the subsection of Σ 0..1 The amount or percentage due from the class beneficiary
. . . subClassDisplay . . valueQuantity SimpleQuantity
. . . . . valueMoney 0..1 string Money Display text for the subsection of the subclass
. . dependent . . exception 0..* string BackboneElement Exceptions for patient payments

Dependent number
. . . . sequence . type Σ 1..1 string CodeableConcept Exception category
Binding: Example Coverage Financial Exception Codes ( Example )
The plan instance or sequence counter
. . order . . . period Σ 0..1 positiveInt Period The effective period of the coverage exception
. . network . subrogation 0..1 string boolean Reimbursement to insurer
Insurer network
. . . 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

UML Diagram ( Legend )

Coverage ( DomainResource ) The main (and possibly only) identifier for of the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatination of the Coverage.SubscriberID and issued by the Coverage.dependant insurer identifier : Identifier [0..*] The status of the resource instance. The status element does not indicate whether the policy reflected in the instance is in-force at any particular point in time, that would be conveyed via the 'period' element (this element modifies the meaning of other elements) status : code [0..1] [1..1] « null (Strength=Required) FinancialResourceStatusCodes ! » A code specifying Used to indicate why the state status has changed statusReason : string [0..1] The nature of the resource instance. coverage be it insurance, or cash payment such as self-pay kind : code [1..1] « null (Strength=Required) Financial Resource Status Kind ! » The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization type : CodeableConcept [0..1] « The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. null (Strength=Preferred) Coverage Type and Self-Pay CoverageTypeAndSelfPayCodes ? » The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer policy policyHolder : Reference [0..1] « Patient | RelatedPerson | Organization » 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 subscriber : Reference [0..1] « Patient | RelatedPerson » The insurer assigned ID for the Subscriber subscriberId : string Identifier [0..1] [0..*] The party who benefits from the insurance coverage., coverage; the patient when products and/or services are provided beneficiary : Reference [0..1] [1..1] « Patient » A designator for a dependent under the coverage dependent : string [0..1] The relationship of beneficiary (patient) to the subscriber relationship : CodeableConcept [0..1] « The relationship between the Policyholder and the Beneficiary (insured/covered party/patient). (Strength=Example) null (Strength=Extensible) Policyholder Relationship SubscriberRelationshipCodes ?? + » 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 force. When non-contiguous periods of coverage need to be documented it is recommended that this is accomplished through the use of an extension,rather than complicating coverage period calculations for many users of the Coverage resource period : Period [0..1] The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements. May provide multiple identifiers such as underwriter, payor, insurance company identifier or business identifier (BIN number) payor insurer : Reference [0..*] [0..1] « Organization | Patient | RelatedPerson A unique identifier for a dependent under the coverage dependent : string [0..1] » « An optional counter for a particular instance of the identified coverage which increments upon each renewal This element has or is affected by some invariants sequence : string C [0..1] » The order of applicability of this coverage relative to other coverages which are currently inforce. in force. Note, there may be gaps in the numbering and this does not imply primary, secondard secondary etc. as the specific positioning of coverages depends upon the episode of care 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 applicable and would apply in the order specified in parenthesis. Coverage.order conveys the Coordination of Benefit (COB) ordering of coverage independent of use-case, for a use-case dependent set of Coverages see Account.coverage.priority order : positiveInt [0..1] 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 network : string [0..1] When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs subrogation : boolean [0..1] The policy(s) which constitute this insurance coverage contract : Reference [0..*] « Contract » The insurance plan details, benefits and costs, which constitute this insurance coverage insurancePlan : Reference [0..1] « InsurancePlan » Group PaymentBy Identifies a style or collective The list of coverage issued by the underwriter, parties providing non-insurance payment for example may be used to identify an employer group. May also be referred to as a Policy or Group ID the treatment costs group party : string Reference [0..1] [1..1] « Patient | RelatedPerson | Organization » A short description for Description of the group financial responsibility groupDisplay responsibility : string [0..1] Class Identifies a style or collective The type of coverage issued by the underwriter, classification for example which an insurer-specific class label or number and optional name is provided. For example, type may be used to identify a subset class of an coverage or employer group group, policy, or plan subGroup type : string CodeableConcept [0..1] [1..1] « null (Strength=Extensible) CoverageClassCodes + » The alphanumeric identifier associated with the insurer issued label value : Identifier [1..1] A short description for the subgroup class subGroupDisplay name : string [0..1] CostToBeneficiary Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a collection The category of benefits provided to employees. May be referred to as a Section or Division ID patient centric costs associated with treatment plan type : string CodeableConcept [0..1] « null (Strength=Extensible) CoverageCopayTypeCodes + » A short description for Code to identify the plan general type of benefits under which products and services are provided planDisplay category : string CodeableConcept [0..1] « null (Strength=Example) BenefitCategoryCodes ?? » Identifies Is a sub-style or sub-collective of coverage issued by the underwriter, for example may be used flag to identify a subset of a collection of indicate whether the benefits provided refer to employees in-network providers or out-of-network providers subPlan network : string CodeableConcept [0..1] « null (Strength=Preferred) NetworkTypeCodes ? » A short description for Indicates if the subplan benefits apply to an individual or to the family subPlanDisplay unit : string CodeableConcept [0..1] « null (Strength=Preferred) UnitTypeCodes ? » Identifies a style The term or collective period of coverage issues by the underwriter, for example may be used to identify a class of coverage values such as a level of deductables 'maximum lifetime benefit' or co-payment 'maximum annual visits' class term : string CodeableConcept [0..1] « null (Strength=Preferred) BenefitTermCodes ? » A short description The amount due from the patient for the class cost category classDisplay value[x] : string DataType [0..1] « Quantity ( SimpleQuantity )| Money » Exception Identifies a sub-style or sub-collective of coverage issues by the underwriter, The code for example may be used to identify a subclass of coverage such as a sub-level of deductables or co-payment the specific exception subClass type : string CodeableConcept [0..1] [1..1] « null (Strength=Example) ExampleCoverageFinancialExcep... ?? » A short description for The timeframe the subclass exception is in force subClassDisplay period : string Period [0..1] Link to the paying party and optionally what specifically they will be responsible to pay paymentBy [0..*] A suite of underwrite underwriter specific classifiers, for example may be used to identify a classifiers class [0..*] A suite of coverage codes indicating exceptions or employer group, Policy, Plan reductions to patient costs and their effective periods grouping exception [0..1] [0..*] 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 costToBeneficiary [0..*]

XML Template 

<

<Coverage xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <
 <</type>
 <</policyHolder>

 <identifier><!-- 0..* Identifier Business identifier(s) for this coverage --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <statusReason value="[string]"/><!-- 0..1 Reason for status change -->
 <kind value="[code]"/><!-- 1..1 insurance | self-pay | other -->
 <paymentBy>  <!-- I 0..* Self-pay parties and responsibility -->
  <party><!-- 1..1 Reference(Organization|Patient|RelatedPerson) Parties performing self-payment --></party>
  <responsibility value="[string]"/><!-- 0..1 Party's responsibility -->
 </paymentBy>
 <type><!-- 0..1 CodeableConcept Coverage category such as medical or accident --></type>
 <policyHolder><!-- 0..1 Reference(Organization|Patient|RelatedPerson) Owner of the policy --></policyHolder>

 <subscriber><!-- 0..1 Reference(Patient|RelatedPerson) Subscriber to the policy --></subscriber>
 <
 <</beneficiary>
 <</relationship>
 <</period>
 <</payor>
 <
  <
  <
  <
  <
  <
  <
  <
  <
  <
  <
  <
  <
 </grouping>
 <
 <
 <
 <

 <subscriberId><!-- 0..* Identifier ID assigned to the subscriber --></subscriberId>
 <beneficiary><!-- 1..1 Reference(Patient) Plan beneficiary --></beneficiary>
 <dependent value="[string]"/><!-- 0..1 Dependent number -->
 <relationship><!-- 0..1 CodeableConcept Beneficiary relationship to the subscriber --></relationship>
 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <insurer><!-- I 0..1 Reference(Organization) Issuer of the policy --></insurer>
 <class>  <!-- 0..* Additional coverage classifications -->
  <type><!-- 1..1 CodeableConcept Type of class such as 'group' or 'plan' --></type>
  <value><!-- 1..1 Identifier Value associated with the type --></value>
  <name value="[string]"/><!-- 0..1 Human readable description of the type and value -->
 </class>
 <order value="[positiveInt]"/><!-- 0..1 Relative order of the coverage -->
 <network value="[string]"/><!-- 0..1 Insurer network -->
 <costToBeneficiary>  <!-- 0..* Patient payments for services/products -->
  <type><!-- 0..1 CodeableConcept Cost category --></type>
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <network><!-- 0..1 CodeableConcept In or out of network --></network>
  <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
  <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
  <value[x]><!-- 0..1 Quantity(SimpleQuantity)|Money The amount or percentage due from the beneficiary --></value[x]>
  <exception>  <!-- 0..* Exceptions for patient payments -->
   <type><!-- 1..1 CodeableConcept Exception category --></type>
   <period><!-- 0..1 Period The effective period of the exception --></period>
  </exception>
 </costToBeneficiary>
 <subrogation value="[boolean]"/><!-- 0..1 Reimbursement to insurer -->

 <contract><!-- 0..* Reference(Contract) Contract details --></contract>
 <insurancePlan><!-- 0..1 Reference(InsurancePlan) Insurance plan details --></insurancePlan>

</Coverage>

JSON Template 

{doco
  "resourceType" : "",

  "resourceType" : "Coverage",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
    "
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    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
  },
  "
  "
  "
  "
  "

  "identifier" : [{ Identifier }], // Business identifier(s) for this coverage
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "statusReason" : "<string>", // Reason for status change
  "kind" : "<code>", // R!  insurance | self-pay | other
  "paymentBy" : [{ // I Self-pay parties and responsibility
    "party" : { Reference(Organization|Patient|RelatedPerson) }, // R!  Parties performing self-payment
    "responsibility" : "<string>" // Party's responsibility
  }],
  "type" : { CodeableConcept }, // Coverage category such as medical or accident
  "policyHolder" : { Reference(Organization|Patient|RelatedPerson) }, // Owner of the policy
  "subscriber" : { Reference(Patient|RelatedPerson) }, // Subscriber to the policy
  "subscriberId" : [{ Identifier }], // ID assigned to the subscriber
  "beneficiary" : { Reference(Patient) }, // R!  Plan beneficiary
  "dependent" : "<string>", // Dependent number
  "relationship" : { CodeableConcept }, // Beneficiary relationship to the subscriber
  "period" : { Period }, // Coverage start and end dates
  "insurer" : { Reference(Organization) }, // I Issuer of the policy
  "class" : [{ // Additional coverage classifications
    "type" : { CodeableConcept }, // R!  Type of class such as 'group' or 'plan'
    "value" : { Identifier }, // R!  Value associated with the type
    "name" : "<string>" // Human readable description of the type and value
  }],
  "order" : "<positiveInt>", // Relative order of the coverage
  "network" : "<string>", // Insurer network
  "costToBeneficiary" : [{ // Patient payments for services/products
    "type" : { CodeableConcept }, // Cost category
    "category" : { CodeableConcept }, // Benefit classification
    "network" : { CodeableConcept }, // In or out of network
    "unit" : { CodeableConcept }, // Individual or family
    "term" : { CodeableConcept }, // Annual or lifetime
    // value[x]: The amount or percentage due from the beneficiary. One of these 2:

    "valueQuantity" : { Quantity(SimpleQuantity) },
    "valueMoney" : { Money },
    "exception" : [{ // Exceptions for patient payments
      "type" : { CodeableConcept }, // R!  Exception category
      "period" : { Period } // The effective period of the exception
    }]
  }],
  "subrogation" : <boolean>, // Reimbursement to insurer
  "contract" : [{ Reference(Contract) }], // Contract details
  "insurancePlan" : { Reference(InsurancePlan) } // Insurance plan details

}

Turtle Template 

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:;

[ a fhir:Coverage;

  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from 
  # from 
  fhir:
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  ];
  fhir:
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  # from Resource: fhir:id, fhir:meta, fhir:implicitRules, and fhir:language
  # from DomainResource: fhir:text, fhir:contained, fhir:extension, and fhir:modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business identifier(s) for this coverage
  fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error
  fhir:statusReason [ string ] ; # 0..1 Reason for status change
  fhir:kind [ code ] ; # 1..1 insurance | self-pay | other
  fhir:paymentBy ( [ # 0..* I Self-pay parties and responsibility
    fhir:party [ Reference(Organization|Patient|RelatedPerson) ] ; # 1..1 Parties performing self-payment
    fhir:responsibility [ string ] ; # 0..1 Party's responsibility
  ] ... ) ;
  fhir:type [ CodeableConcept ] ; # 0..1 Coverage category such as medical or accident
  fhir:policyHolder [ Reference(Organization|Patient|RelatedPerson) ] ; # 0..1 Owner of the policy
  fhir:subscriber [ Reference(Patient|RelatedPerson) ] ; # 0..1 Subscriber to the policy
  fhir:subscriberId  ( [ Identifier ] ... ) ; # 0..* ID assigned to the subscriber
  fhir:beneficiary [ Reference(Patient) ] ; # 1..1 Plan beneficiary
  fhir:dependent [ string ] ; # 0..1 Dependent number
  fhir:relationship [ CodeableConcept ] ; # 0..1 Beneficiary relationship to the subscriber
  fhir:period [ Period ] ; # 0..1 Coverage start and end dates
  fhir:insurer [ Reference(Organization) ] ; # 0..1 I Issuer of the policy
  fhir:class ( [ # 0..* Additional coverage classifications
    fhir:type [ CodeableConcept ] ; # 1..1 Type of class such as 'group' or 'plan'
    fhir:value [ Identifier ] ; # 1..1 Value associated with the type
    fhir:name [ string ] ; # 0..1 Human readable description of the type and value
  ] ... ) ;
  fhir:order [ positiveInt ] ; # 0..1 Relative order of the coverage
  fhir:network [ string ] ; # 0..1 Insurer network
  fhir:costToBeneficiary ( [ # 0..* Patient payments for services/products
    fhir:type [ CodeableConcept ] ; # 0..1 Cost category
    fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
    fhir:network [ CodeableConcept ] ; # 0..1 In or out of network
    fhir:unit [ CodeableConcept ] ; # 0..1 Individual or family
    fhir:term [ CodeableConcept ] ; # 0..1 Annual or lifetime
    # value[x] : 0..1 The amount or percentage due from the beneficiary. One of these 2
      fhir:value [  a fhir:SimpleQuantity ; Quantity(SimpleQuantity) ]
      fhir:value [  a fhir:Money ; Money ]
    fhir:exception ( [ # 0..* Exceptions for patient payments
      fhir:type [ CodeableConcept ] ; # 1..1 Exception category
      fhir:period [ Period ] ; # 0..1 The effective period of the exception
    ] ... ) ;
  ] ... ) ;
  fhir:subrogation [ boolean ] ; # 0..1 Reimbursement to insurer
  fhir:contract  ( [ Reference(Contract) ] ... ) ; # 0..* Contract details
  fhir:insurancePlan [ Reference(InsurancePlan) ] ; # 0..1 Insurance plan details

]

Changes since DSTU2 from both R4 and R4B

Coverage.status Added Element Coverage.type Type changed from Coding to CodeableConcept Coverage.policyHolder Added Element Coverage.subscriber Add Reference(RelatedPerson) No longer marked as Modifier Coverage.subscriberId Type changed from Identifier to string Coverage.beneficiary Added Element Coverage.relationship Added Element Coverage.payor Coverage.network Type changed from Identifier to string Coverage.issuer deleted Coverage.bin deleted Coverage.group deleted Coverage.plan deleted
Coverage Added Element
Coverage.grouping Coverage.statusReason
  • Added Element
Coverage.grouping.group Coverage.kind
  • Added Mandatory Element
Coverage.grouping.groupDisplay Coverage.paymentBy
  • Added Element
Coverage.grouping.subGroup Coverage.paymentBy.party
  • Added Mandatory Element
Coverage.grouping.subGroupDisplay Coverage.paymentBy.responsibility
  • Added Element
Coverage.grouping.plan Coverage.subscriberId
  • Added Element Max Cardinality changed from 1 to *
    • Coverage.grouping.planDisplay
  • Added Element Type changed from string to Identifier
Coverage.grouping.subPlan Coverage.insurer
  • Added Element
Coverage.grouping.subPlanDisplay Coverage.class.value
  • Added Element Type changed from string to Identifier
Coverage.grouping.class Coverage.costToBeneficiary.category
  • Added Element
Coverage.grouping.classDisplay Coverage.costToBeneficiary.network
  • Added Element
Coverage.grouping.subClass Coverage.costToBeneficiary.unit
  • Added Element
Coverage.grouping.subClassDisplay Coverage.costToBeneficiary.term
  • Added Element
Coverage.dependent Type changed from positiveInt to string Coverage.sequence Coverage.costToBeneficiary.value[x]
  • Type Min Cardinality changed from positiveInt 1 to string 0
Coverage.order Coverage.insurancePlan
  • Added Element
Coverage.subPlan Coverage.payor
  • deleted Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON .

Structure

The primary 0..1 Type of coverage 0..1 0..1 Identifier for 0..1 0..1 Display text for an identifier for An identifier for the subsection Display text for the subsection Σ 0..1 Display text Σ Σ Σ string Σ Σ 0..1 0..1 Relative order Σ
Name Flags Card. Type Description & Constraints      Filter: Filters doco
. . Coverage N 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 ID

. . . status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes ( Required )
. . type . statusReason Σ 0..1 string Reason for status change
. . . paymentBy C 0..* BackboneElement Self-pay parties and responsibility

.... 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..* string Identifier ID assigned to the Subscriber subscriber

. . . beneficiary Σ 1..1 Reference ( Patient ) Plan Beneficiary beneficiary
. . relationship . dependent Σ 0..1 string Dependent number
. . . relationship 0..1 CodeableConcept Beneficiary relationship to the Subscriber subscriber
Policyholder Binding: SubscriberPolicyholder Relationship Codes ( Example Extensible )
. . . period Σ 0..1 Period Coverage start and end dates
. . . payor insurer Σ C 0..* 0..1 Reference ( Organization | Patient | RelatedPerson ) Issuer of the plan or agreement issuer policy
. . grouping . class 0..1 0..* BackboneElement Additional coverage classifications

. . . group . type Σ 1..1 string CodeableConcept Type of class such as 'group' or 'plan'
Binding: Coverage Class Codes ( Extensible )
An identifier for the group
. . . groupDisplay . value Σ 1..1 string Identifier Value associated with the group type
. . . . subGroup name Σ 0..1 string Human readable description of the group type and value
. . subGroupDisplay . order Σ 0..1 string positiveInt Relative order of the group coverage
. . . plan network Σ 0..1 string Insurer network
An identifier for the plan
. . planDisplay . costToBeneficiary 0..* string BackboneElement Patient payments for the plan services/products

. . . subPlan . type Σ 0..1 string CodeableConcept Cost category
Binding: Coverage Copay Type Codes ( Extensible )
An identifier for the subsection of the plan
. . . subPlanDisplay . category 0..1 string CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
Display text for the subsection of the plan
. . . class . network 0..1 string CodeableConcept In or out of network
Binding: Network Type Codes ( Preferred )
An identifier for the class
. . . classDisplay . unit 0..1 string CodeableConcept Individual or family
Binding: Unit Type Codes ( Preferred )
Display text for the class
. . . subClass . term 0..1 Σ CodeableConcept Annual or lifetime
Binding: Benefit Term Codes ( Preferred )
0..1
. . . . value[x] An identifier for the subsection of Σ 0..1 The amount or percentage due from the class beneficiary
. . . subClassDisplay . . valueQuantity SimpleQuantity
. . . . . valueMoney 0..1 string Money Display text for the subsection of the subclass
. . dependent . . exception 0..* string BackboneElement Exceptions for patient payments

Dependent number
. . . . sequence . type Σ 1..1 string CodeableConcept Exception category
Binding: Example Coverage Financial Exception Codes ( Example )
The plan instance or sequence counter
. . order . . . period Σ 0..1 positiveInt Period The effective period of the coverage exception
. . network . subrogation 0..1 string boolean Reimbursement to insurer
Insurer network
. . . 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

UML Diagram ( Legend )

Coverage ( DomainResource ) The main (and possibly only) identifier for of the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as issued by the concatination of the Coverage.SubscriberID and the Coverage.dependant insurer identifier : Identifier [0..*] The status of the resource instance. The status element does not indicate whether the policy reflected in the instance is in-force at any particular point in time, that would be conveyed via the 'period' element (this element modifies the meaning of other elements) status : code [0..1] [1..1] « null (Strength=Required) FinancialResourceStatusCodes ! » A code specifying Used to indicate why the state status has changed statusReason : string [0..1] The nature of the resource instance. coverage be it insurance, or cash payment such as self-pay kind : code [1..1] « null (Strength=Required) Financial Resource Status Kind ! » The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization type : CodeableConcept [0..1] « The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. null (Strength=Preferred) Coverage Type and Self-Pay CoverageTypeAndSelfPayCodes ? » The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer policy policyHolder : Reference [0..1] « Patient | RelatedPerson | Organization » 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 subscriber : Reference [0..1] « Patient | RelatedPerson » The insurer assigned ID for the Subscriber subscriberId : string Identifier [0..1] [0..*] The party who benefits from the insurance coverage., coverage; the patient when products and/or services are provided beneficiary : Reference [0..1] [1..1] « Patient » A designator for a dependent under the coverage dependent : string [0..1] The relationship of beneficiary (patient) to the subscriber relationship : CodeableConcept [0..1] « The relationship between the Policyholder and the Beneficiary (insured/covered party/patient). (Strength=Example) null (Strength=Extensible) Policyholder Relationship SubscriberRelationshipCodes ?? + » 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 force. When non-contiguous periods of coverage need to be documented it is recommended that this is accomplished through the use of an extension,rather than complicating coverage period calculations for many users of the Coverage resource period : Period [0..1] The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements. May provide multiple identifiers such as underwriter, payor, insurance company identifier or business identifier (BIN number) payor insurer : Reference [0..*] [0..1] « Organization | Patient | RelatedPerson A unique identifier for a dependent under the coverage dependent : string [0..1] » « An optional counter for a particular instance of the identified coverage which increments upon each renewal This element has or is affected by some invariants sequence : string C [0..1] » The order of applicability of this coverage relative to other coverages which are currently inforce. in force. Note, there may be gaps in the numbering and this does not imply primary, secondard secondary etc. as the specific positioning of coverages depends upon the episode of care 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 applicable and would apply in the order specified in parenthesis. Coverage.order conveys the Coordination of Benefit (COB) ordering of coverage independent of use-case, for a use-case dependent set of Coverages see Account.coverage.priority order : positiveInt [0..1] 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 network : string [0..1] When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs subrogation : boolean [0..1] The policy(s) which constitute this insurance coverage contract : Reference [0..*] « Contract » The insurance plan details, benefits and costs, which constitute this insurance coverage insurancePlan : Reference [0..1] « InsurancePlan » Group PaymentBy Identifies a style or collective The list of coverage issued by the underwriter, parties providing non-insurance payment for example may be used to identify an employer group. May also be referred to as a Policy or Group ID the treatment costs group party : string Reference [0..1] [1..1] « Patient | RelatedPerson | Organization » A short description for Description of the group financial responsibility groupDisplay responsibility : string [0..1] Class Identifies a style or collective The type of coverage issued by the underwriter, classification for example which an insurer-specific class label or number and optional name is provided. For example, type may be used to identify a subset class of an coverage or employer group group, policy, or plan subGroup type : string CodeableConcept [0..1] [1..1] « null (Strength=Extensible) CoverageClassCodes + » The alphanumeric identifier associated with the insurer issued label value : Identifier [1..1] A short description for the subgroup class subGroupDisplay name : string [0..1] CostToBeneficiary Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a collection The category of benefits provided to employees. May be referred to as a Section or Division ID patient centric costs associated with treatment plan type : string CodeableConcept [0..1] « null (Strength=Extensible) CoverageCopayTypeCodes + » A short description for Code to identify the plan general type of benefits under which products and services are provided planDisplay category : string CodeableConcept [0..1] « null (Strength=Example) BenefitCategoryCodes ?? » Identifies Is a sub-style or sub-collective of coverage issued by the underwriter, for example may be used flag to identify a subset of a collection of indicate whether the benefits provided refer to employees in-network providers or out-of-network providers subPlan network : string CodeableConcept [0..1] « null (Strength=Preferred) NetworkTypeCodes ? » A short description for Indicates if the subplan benefits apply to an individual or to the family subPlanDisplay unit : string CodeableConcept [0..1] « null (Strength=Preferred) UnitTypeCodes ? » Identifies a style The term or collective period of coverage issues by the underwriter, for example may be used to identify a class of coverage values such as a level of deductables 'maximum lifetime benefit' or co-payment 'maximum annual visits' class term : string CodeableConcept [0..1] « null (Strength=Preferred) BenefitTermCodes ? » A short description The amount due from the patient for the class cost category classDisplay value[x] : string DataType [0..1] « Quantity ( SimpleQuantity )| Money » Exception Identifies a sub-style or sub-collective of coverage issues by the underwriter, The code for example may be used to identify a subclass of coverage such as a sub-level of deductables or co-payment the specific exception subClass type : string CodeableConcept [0..1] [1..1] « null (Strength=Example) ExampleCoverageFinancialExcep... ?? » A short description for The timeframe the subclass exception is in force subClassDisplay period : string Period [0..1] Link to the paying party and optionally what specifically they will be responsible to pay paymentBy [0..*] A suite of underwrite underwriter specific classifiers, for example may be used to identify a classifiers class [0..*] A suite of coverage codes indicating exceptions or employer group, Policy, Plan reductions to patient costs and their effective periods grouping exception [0..1] [0..*] 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 costToBeneficiary [0..*]

XML Template 

<

<Coverage xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <
 <</type>
 <</policyHolder>

 <identifier><!-- 0..* Identifier Business identifier(s) for this coverage --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <statusReason value="[string]"/><!-- 0..1 Reason for status change -->
 <kind value="[code]"/><!-- 1..1 insurance | self-pay | other -->
 <paymentBy>  <!-- I 0..* Self-pay parties and responsibility -->
  <party><!-- 1..1 Reference(Organization|Patient|RelatedPerson) Parties performing self-payment --></party>
  <responsibility value="[string]"/><!-- 0..1 Party's responsibility -->
 </paymentBy>
 <type><!-- 0..1 CodeableConcept Coverage category such as medical or accident --></type>
 <policyHolder><!-- 0..1 Reference(Organization|Patient|RelatedPerson) Owner of the policy --></policyHolder>

 <subscriber><!-- 0..1 Reference(Patient|RelatedPerson) Subscriber to the policy --></subscriber>
 <
 <</beneficiary>
 <</relationship>
 <</period>
 <</payor>
 <
  <
  <
  <
  <
  <
  <
  <
  <
  <
  <
  <
  <
 </grouping>
 <
 <
 <
 <

 <subscriberId><!-- 0..* Identifier ID assigned to the subscriber --></subscriberId>
 <beneficiary><!-- 1..1 Reference(Patient) Plan beneficiary --></beneficiary>
 <dependent value="[string]"/><!-- 0..1 Dependent number -->
 <relationship><!-- 0..1 CodeableConcept Beneficiary relationship to the subscriber --></relationship>
 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <insurer><!-- I 0..1 Reference(Organization) Issuer of the policy --></insurer>
 <class>  <!-- 0..* Additional coverage classifications -->
  <type><!-- 1..1 CodeableConcept Type of class such as 'group' or 'plan' --></type>
  <value><!-- 1..1 Identifier Value associated with the type --></value>
  <name value="[string]"/><!-- 0..1 Human readable description of the type and value -->
 </class>
 <order value="[positiveInt]"/><!-- 0..1 Relative order of the coverage -->
 <network value="[string]"/><!-- 0..1 Insurer network -->
 <costToBeneficiary>  <!-- 0..* Patient payments for services/products -->
  <type><!-- 0..1 CodeableConcept Cost category --></type>
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <network><!-- 0..1 CodeableConcept In or out of network --></network>
  <unit><!-- 0..1 CodeableConcept Individual or family --></unit>
  <term><!-- 0..1 CodeableConcept Annual or lifetime --></term>
  <value[x]><!-- 0..1 Quantity(SimpleQuantity)|Money The amount or percentage due from the beneficiary --></value[x]>
  <exception>  <!-- 0..* Exceptions for patient payments -->
   <type><!-- 1..1 CodeableConcept Exception category --></type>
   <period><!-- 0..1 Period The effective period of the exception --></period>
  </exception>
 </costToBeneficiary>
 <subrogation value="[boolean]"/><!-- 0..1 Reimbursement to insurer -->

 <contract><!-- 0..* Reference(Contract) Contract details --></contract>
 <insurancePlan><!-- 0..1 Reference(InsurancePlan) Insurance plan details --></insurancePlan>

</Coverage>

JSON Template 

{doco
  "resourceType" : "",

  "resourceType" : "Coverage",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
  },
  "
  "
  "
  "
  "

  "identifier" : [{ Identifier }], // Business identifier(s) for this coverage
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "statusReason" : "<string>", // Reason for status change
  "kind" : "<code>", // R!  insurance | self-pay | other
  "paymentBy" : [{ // I Self-pay parties and responsibility
    "party" : { Reference(Organization|Patient|RelatedPerson) }, // R!  Parties performing self-payment
    "responsibility" : "<string>" // Party's responsibility
  }],
  "type" : { CodeableConcept }, // Coverage category such as medical or accident
  "policyHolder" : { Reference(Organization|Patient|RelatedPerson) }, // Owner of the policy
  "subscriber" : { Reference(Patient|RelatedPerson) }, // Subscriber to the policy
  "subscriberId" : [{ Identifier }], // ID assigned to the subscriber
  "beneficiary" : { Reference(Patient) }, // R!  Plan beneficiary
  "dependent" : "<string>", // Dependent number
  "relationship" : { CodeableConcept }, // Beneficiary relationship to the subscriber
  "period" : { Period }, // Coverage start and end dates
  "insurer" : { Reference(Organization) }, // I Issuer of the policy
  "class" : [{ // Additional coverage classifications
    "type" : { CodeableConcept }, // R!  Type of class such as 'group' or 'plan'
    "value" : { Identifier }, // R!  Value associated with the type
    "name" : "<string>" // Human readable description of the type and value
  }],
  "order" : "<positiveInt>", // Relative order of the coverage
  "network" : "<string>", // Insurer network
  "costToBeneficiary" : [{ // Patient payments for services/products
    "type" : { CodeableConcept }, // Cost category
    "category" : { CodeableConcept }, // Benefit classification
    "network" : { CodeableConcept }, // In or out of network
    "unit" : { CodeableConcept }, // Individual or family
    "term" : { CodeableConcept }, // Annual or lifetime
    // value[x]: The amount or percentage due from the beneficiary. One of these 2:

    "valueQuantity" : { Quantity(SimpleQuantity) },
    "valueMoney" : { Money },
    "exception" : [{ // Exceptions for patient payments
      "type" : { CodeableConcept }, // R!  Exception category
      "period" : { Period } // The effective period of the exception
    }]
  }],
  "subrogation" : <boolean>, // Reimbursement to insurer
  "contract" : [{ Reference(Contract) }], // Contract details
  "insurancePlan" : { Reference(InsurancePlan) } // Insurance plan details

}

Turtle Template 

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:;

[ a fhir:Coverage;

  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from 
  # from 
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ];
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:

  # from Resource: fhir:id, fhir:meta, fhir:implicitRules, and fhir:language
  # from DomainResource: fhir:text, fhir:contained, fhir:extension, and fhir:modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business identifier(s) for this coverage
  fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error
  fhir:statusReason [ string ] ; # 0..1 Reason for status change
  fhir:kind [ code ] ; # 1..1 insurance | self-pay | other
  fhir:paymentBy ( [ # 0..* I Self-pay parties and responsibility
    fhir:party [ Reference(Organization|Patient|RelatedPerson) ] ; # 1..1 Parties performing self-payment
    fhir:responsibility [ string ] ; # 0..1 Party's responsibility
  ] ... ) ;
  fhir:type [ CodeableConcept ] ; # 0..1 Coverage category such as medical or accident
  fhir:policyHolder [ Reference(Organization|Patient|RelatedPerson) ] ; # 0..1 Owner of the policy
  fhir:subscriber [ Reference(Patient|RelatedPerson) ] ; # 0..1 Subscriber to the policy
  fhir:subscriberId  ( [ Identifier ] ... ) ; # 0..* ID assigned to the subscriber
  fhir:beneficiary [ Reference(Patient) ] ; # 1..1 Plan beneficiary
  fhir:dependent [ string ] ; # 0..1 Dependent number
  fhir:relationship [ CodeableConcept ] ; # 0..1 Beneficiary relationship to the subscriber
  fhir:period [ Period ] ; # 0..1 Coverage start and end dates
  fhir:insurer [ Reference(Organization) ] ; # 0..1 I Issuer of the policy
  fhir:class ( [ # 0..* Additional coverage classifications
    fhir:type [ CodeableConcept ] ; # 1..1 Type of class such as 'group' or 'plan'
    fhir:value [ Identifier ] ; # 1..1 Value associated with the type
    fhir:name [ string ] ; # 0..1 Human readable description of the type and value
  ] ... ) ;
  fhir:order [ positiveInt ] ; # 0..1 Relative order of the coverage
  fhir:network [ string ] ; # 0..1 Insurer network
  fhir:costToBeneficiary ( [ # 0..* Patient payments for services/products
    fhir:type [ CodeableConcept ] ; # 0..1 Cost category
    fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
    fhir:network [ CodeableConcept ] ; # 0..1 In or out of network
    fhir:unit [ CodeableConcept ] ; # 0..1 Individual or family
    fhir:term [ CodeableConcept ] ; # 0..1 Annual or lifetime
    # value[x] : 0..1 The amount or percentage due from the beneficiary. One of these 2
      fhir:value [  a fhir:SimpleQuantity ; Quantity(SimpleQuantity) ]
      fhir:value [  a fhir:Money ; Money ]
    fhir:exception ( [ # 0..* Exceptions for patient payments
      fhir:type [ CodeableConcept ] ; # 1..1 Exception category
      fhir:period [ Period ] ; # 0..1 The effective period of the exception
    ] ... ) ;
  ] ... ) ;
  fhir:subrogation [ boolean ] ; # 0..1 Reimbursement to insurer
  fhir:contract  ( [ Reference(Contract) ] ... ) ; # 0..* Contract details
  fhir:insurancePlan [ Reference(InsurancePlan) ] ; # 0..1 Insurance plan details

]

Changes since DSTU2 from both R4 and R4B

Coverage.status Added Element Coverage.type Type changed from Coding to CodeableConcept Coverage.policyHolder Added Element Coverage.subscriber Add Reference(RelatedPerson) No longer marked as Modifier Coverage.subscriberId Type changed from Identifier to string Coverage.beneficiary Added Element Coverage.relationship Added Element Coverage.payor Coverage.network Type changed from Identifier to string Coverage.issuer deleted Coverage.bin deleted Coverage.group deleted Coverage.plan deleted
Coverage Added Element
Coverage.grouping Coverage.statusReason
  • Added Element
Coverage.grouping.group Coverage.kind
  • Added Mandatory Element
Coverage.grouping.groupDisplay Coverage.paymentBy
  • Added Element
Coverage.grouping.subGroup Coverage.paymentBy.party
  • Added Mandatory Element
Coverage.grouping.subGroupDisplay Coverage.paymentBy.responsibility
  • Added Element
Coverage.grouping.plan Coverage.subscriberId
  • Added Element Max Cardinality changed from 1 to *
    • Coverage.grouping.planDisplay
  • Added Element Type changed from string to Identifier
Coverage.grouping.subPlan Coverage.insurer
  • Added Element
Coverage.grouping.subPlanDisplay Coverage.class.value
  • Added Element Type changed from string to Identifier
Coverage.grouping.class Coverage.costToBeneficiary.category
  • Added Element
Coverage.grouping.classDisplay Coverage.costToBeneficiary.network
  • Added Element
Coverage.grouping.subClass Coverage.costToBeneficiary.unit
  • Added Element
Coverage.grouping.subClassDisplay Coverage.costToBeneficiary.term
  • Added Element
Coverage.dependent Type changed from positiveInt to string Coverage.sequence Coverage.costToBeneficiary.value[x]
  • Type Min Cardinality changed from positiveInt 1 to string 0
Coverage.order Coverage.insurancePlan
  • Added Element
Coverage.subPlan Coverage.payor
  • deleted Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON .

 

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

13.1.2.1 13.1.4.1 Terminology Bindings

Coverage.type
Path Definition ValueSet Type Reference Documentation
Coverage.status A code specifying the state of the resource instance. FinancialResourceStatusCodes Required Financial Resource

This value set includes Status Codes codes.

Coverage.kind Kind Required

The type kind of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual coverage: insurance, selfpay or organization. other.

Coverage.type CoverageTypeAndSelfPayCodes Preferred

This value set includes Coverage Type and Self-Pay Codes codes.

Coverage.relationship SubscriberRelationshipCodes (a valid code from SubscriberPolicyholder Relationship Codes icon ) Extensible The

This value set includes codes for the relationship between the Policyholder 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 Preferred

This value set includes a smattering of Network type codes.

Coverage.costToBeneficiary.unit UnitTypeCodes Preferred Policyholder Relationship Codes

This value set includes a smattering of Unit type codes.

Coverage.costToBeneficiary.term BenefitTermCodes Preferred

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.

13.1.4.2 Constraints

UniqueKey Level Location Description Expression
img  cov-insured-1 Rule Coverage.kind When patient is insured, insurer must exist. %resource.kind = 'insurance' implies (%resource.insurer.exists() and %resource.paymentBy.empty())
img  cov-self-pay-1 Rule Coverage.kind When patient is self-pay, paymentBy must exist. %resource.kind = 'self-pay' implies (%resource.insurer.empty() and %resource.paymentBy.exists())

13.1.3 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 class string token Class identifier Coverage class (e.g. plan, group) Coverage.grouping.class Coverage.class.type
class-value dependent string token Dependent number Value of the class (e.g. Plan number, group number) Coverage.dependent Coverage.class.value
dependent group string Group identifier Dependent number Coverage.grouping.group Coverage.dependent
identifier token The primary identifier of the insured and the coverage Coverage.identifier 58 Resources
payor insurer reference The identity of the insurer or party paying for services Coverage.payor Coverage.insurer
( Organization , Patient , RelatedPerson )
plan patient string reference A plan or policy identifier Retrieve coverages for a patient Coverage.grouping.plan Coverage.beneficiary
( Patient ) 		60 Resources
paymentby-party policy-holder reference Reference to the policyholder Parties who will pay for services Coverage.policyHolder Coverage.paymentBy.party
( Organization , Patient , RelatedPerson )
period sequence string date Sequence number Dates that the Coverage is active Coverage.sequence Coverage.period
subclass string policy-holder Sub-class identifier Coverage.grouping.subClass reference subgroup Reference to the policyholder string Coverage.policyHolder
( Organization , Patient , RelatedPerson ) 		Sub-group identifier Coverage.grouping.subGroup
subplan status string token Sub-plan identifier The status of the Coverage Coverage.grouping.subPlan 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 10 Resources