DSTU2 STU 3 Candidate
This page is part of the FHIR Specification (v1.0.2: DSTU 2). The current version which supercedes this version is

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . For a full list of available versions, see the Directory of published versions . Page versions: . Page versions: R5 R4B R4 R3 R2

7.3 Resource Coverage - Content Resource Coverage - Content

Financial instrument which may be used to pay for or reimburse health care products and services.
Financial Management Financial Management Work Group Work Group Maturity Level : 0 Maturity Level : 0 Compartments : Not linked to any defined compartments : Not linked to any defined compartments

Financial instrument which may be used to pay for or reimburse health care products and services.

7.3.1 Scope and Usage Scope and Usage The Coverage resource is intended to provide the high level identifiers and potentially descriptors of insurance plans which may used to pay for, in part or in whole, the provision of health care products and services. Todo This resource is referenced by

The Coverage resource is intended to provide the high level identifiers and potentially descriptors of insurance plans which may used to pay for, in part or in whole, the provision of health care products and services. Todo

This resource is referenced by Claim , , ClaimResponse and , EligibilityRequest , EnrollmentRequest and ExplanationOfBenefit

7.3.2 Resource Content Resource Content

Structure

An identifier for the plan issuer
Name Flags Card. Type Description & Constraints Description & Constraints doco
. . Coverage DomainResource Insurance or medical plan Insurance or medical plan
. . issuer . issuer[x] Σ 0..1 1..1 Identifier for the plan issuer
.... issuerIdentifier Identifier
.... issuerReference Reference ( Organization )
. . . bin 0..1 Identifier string BIN Number BIN Number
. . . period Σ 0..1 Period Coverage start and end dates Coverage start and end dates
. . . type Σ 0..1 Coding Type of coverage Type of coverage
ActCoverageTypeCode ( ( Example )
. . subscriberId . planholder[x] ?! 1..1 Plan holder
.... planholderIdentifier Identifier
. . . . planholderReference Σ Reference ( Patient | Organization )
... beneficiary[x] ?! 0..1 1..1 Plan Beneficiary
.... beneficiaryIdentifier Identifier
. . . . beneficiaryReference Subscriber ID Reference ( Patient )
. . identifier . relationship 1..1 Coding Patient relationship to planholder
Beneficiary Relationship Codes ( Example )
... identifier Σ 0..* Identifier The primary coverage ID The primary coverage ID
. . . group Σ 0..1 string An identifier for the group An identifier for the group
. . . plan Σ 0..1 string An identifier for the plan An identifier for the plan
. . . subPlan Σ 0..1 string An identifier for the subsection of the plan An identifier for the subsection of the plan
. . . dependent Σ 0..1 positiveInt The dependent number Dependent number
. . . sequence Σ 0..1 positiveInt The plan instance or sequence counter The plan instance or sequence counter
. . subscriber . exception 0..* Coding Eligibility exceptions
?! Exception Codes ( Example )
... school 0..1 Reference ( Patient string ) Plan holder information Name of School
. . . network Σ 0..1 Identifier string Insurer network Insurer network
. . . contract 0..* Reference ( Contract ) Contract details Contract details

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram

Coverage ( ( DomainResource ) The program or plan underwriter or payor The program or plan underwriter or payor issuer issuer[x] : Type [1..1] « Identifier : | Reference [0..1] « ( Organization » ) » Business Identification Number (BIN number) used to identify the routing of eclaims if the insurer themselves don't have a BIN number for all of their business Business Identification Number (BIN number) used to identify the routing of eClaims bin : Identifier [0..1] : string [0..1] 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 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 period : : Period [0..1] [0..1] The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health type : : Coding [0..1] « [0..1] « The type of insurance: public health, worker compensation; private accident, auto, private health, etc.). (Strength=Example) The type of insurance: public health, worker compensation; private accident, auto, private health, etc.). (Strength=Example) ActCoverageTypeCode ?? » ?? » The id issued to the subscriber The party who 'owns' the insurance contractual relationship to the policy or to whom the benefit of the policy is due (this element modifies the meaning of other elements) subscriberId planholder[x] : Type [1..1] « Identifier : | Reference ( Patient | Organization ) » The party who benefits from the insurance coverage (this element modifies the meaning of other elements) beneficiary[x] : Type [1..1] « Identifier [0..1] | Reference ( Patient ) » The relationship of the patient to the planholdersubscriber) relationship : Coding [1..1] « The code for the relationship of the patient to the subscriber. (Strength=Example) Beneficiary Relationship ?? » The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Subscriber Id, Certificate number or Personal Health Number or Case ID The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Subscriber Id, Certificate number or Personal Health Number or Case ID identifier : : Identifier [0..*] [0..*] Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer group. May also be referred to as a Policy or Group ID Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer group. May also be referred to as a Policy or Group ID group : : string [0..1] [0..1] Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer group. May also be referred to as a Policy or Group ID Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer group. May also be referred to as a Policy or Group ID plan : : string [0..1] [0..1] Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a specific employer group within a class of employers. May be referred to as a Section or Division ID Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a specific employer group within a class of employers. May be referred to as a Section or Division ID subPlan : : string [0..1] [0..1] A unique identifier for a dependent under the coverage A unique identifier for a dependent under the coverage dependent : : positiveInt [0..1] [0..1] An optional counter for a particular instance of the identified coverage which increments upon each renewal An optional counter for a particular instance of the identified coverage which increments upon each renewal sequence : : positiveInt [0..1] [0..1] The party who 'owns' the insurance contractual relationship to the policy or to whom the benefit of the policy is due (this element modifies the meaning of other elements) Factors which may influence the applicability of coverage subscriber : Reference [0..1] « Patient » exception : Coding [0..*] « The eligibility exception codes. (Strength=Example) Exception ?? » Name of school for over-aged dependants school : string [0..1] The identifier for a community of providers The identifier for a community of providers network : Identifier [0..1] : string [0..1] The policy(s) which constitute this insurance coverage The policy(s) which constitute this insurance coverage contract : : Reference [0..*] « [0..*] « Contract » »

XML Template XML Template 

<Coverage xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</issuer>
 <</bin>

 <issuer[x]><!-- 1..1 Identifier|Reference(Organization) Identifier for the plan issuer --></issuer[x]>
 <bin value="[string]"/><!-- 0..1 BIN Number -->

 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <</type>
 <</subscriberId>

 <type><!-- 0..1 Coding Type of coverage --></type>
 <planholder[x]><!-- 1..1 Identifier|Reference(Patient|Organization) Plan holder --></planholder[x]>
 <beneficiary[x]><!-- 1..1 Identifier|Reference(Patient) Plan Beneficiary --></beneficiary[x]>
 <relationship><!-- 1..1 Coding Patient relationship to planholder --></relationship>

 <identifier><!-- 0..* Identifier The primary coverage ID --></identifier>
 <group value="[string]"/><!-- 0..1 An identifier for the group -->
 <plan value="[string]"/><!-- 0..1 An identifier for the plan -->
 <subPlan value="[string]"/><!-- 0..1 An identifier for the subsection of the plan -->
 <

 <dependent value="[positiveInt]"/><!-- 0..1 Dependent number -->

 <sequence value="[positiveInt]"/><!-- 0..1 The plan instance or sequence counter -->
 <</subscriber>
 <</network>

 <exception><!-- 0..* Coding Eligibility exceptions --></exception>
 <school value="[string]"/><!-- 0..1 Name of School -->
 <network value="[string]"/><!-- 0..1 Insurer network -->

 <contract><!-- 0..* Reference(Contract) Contract details --></contract>
</Coverage>

JSON Template JSON Template

Structure

An identifier for the plan issuer
Name Flags Card. Type Description & Constraints Description & Constraints doco
. . Coverage DomainResource Insurance or medical plan Insurance or medical plan
. . issuer . issuer[x] Σ 0..1 1..1 Identifier for the plan issuer
.... issuerIdentifier Identifier
. . . . issuerReference Reference ( Organization )
. . . bin 0..1 Identifier string BIN Number BIN Number
. . . period Σ 0..1 Period Coverage start and end dates Coverage start and end dates
. . . type Σ 0..1 Coding Type of coverage Type of coverage
ActCoverageTypeCode ( ( Example )
. . subscriberId . planholder[x] ?! 1..1 Plan holder
.... planholderIdentifier Identifier
. . . . planholderReference Σ Reference ( Patient | Organization )
... beneficiary[x] ?! 0..1 1..1 Plan Beneficiary
. . . . beneficiaryIdentifier Identifier
. . . . beneficiaryReference Subscriber ID Reference ( Patient )
. . identifier . relationship 1..1 Coding Patient relationship to planholder
Beneficiary Relationship Codes ( Example )
... identifier Σ 0..* Identifier The primary coverage ID The primary coverage ID
. . . group Σ 0..1 string An identifier for the group An identifier for the group
. . . plan Σ 0..1 string An identifier for the plan An identifier for the plan
. . . subPlan Σ 0..1 string An identifier for the subsection of the plan An identifier for the subsection of the plan
. . . dependent Σ 0..1 positiveInt The dependent number Dependent number
. . . sequence Σ 0..1 positiveInt The plan instance or sequence counter The plan instance or sequence counter
. . subscriber . exception 0..* Coding Eligibility exceptions
?! Exception Codes ( Example )
... school 0..1 Reference ( Patient string ) Plan holder information Name of School
. . . network Σ 0..1 Identifier string Insurer network Insurer network
. . . contract 0..* Reference ( Contract ) Contract details Contract details

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram

Coverage ( ( DomainResource ) The program or plan underwriter or payor The program or plan underwriter or payor issuer issuer[x] : Type [1..1] « Identifier : | Reference [0..1] « ( Organization » ) » Business Identification Number (BIN number) used to identify the routing of eclaims if the insurer themselves don't have a BIN number for all of their business Business Identification Number (BIN number) used to identify the routing of eClaims bin : Identifier [0..1] : string [0..1] 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 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 period : : Period [0..1] [0..1] The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health type : : Coding [0..1] « [0..1] « The type of insurance: public health, worker compensation; private accident, auto, private health, etc.). (Strength=Example) The type of insurance: public health, worker compensation; private accident, auto, private health, etc.). (Strength=Example) ActCoverageTypeCode ?? » ?? » The id issued to the subscriber The party who 'owns' the insurance contractual relationship to the policy or to whom the benefit of the policy is due (this element modifies the meaning of other elements) subscriberId planholder[x] : Type [1..1] « Identifier : | Reference ( Patient | Organization ) » The party who benefits from the insurance coverage (this element modifies the meaning of other elements) beneficiary[x] : Type [1..1] « Identifier [0..1] | Reference ( Patient ) » The relationship of the patient to the planholdersubscriber) relationship : Coding [1..1] « The code for the relationship of the patient to the subscriber. (Strength=Example) Beneficiary Relationship ?? » The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Subscriber Id, Certificate number or Personal Health Number or Case ID The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Subscriber Id, Certificate number or Personal Health Number or Case ID identifier : : Identifier [0..*] [0..*] Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer group. May also be referred to as a Policy or Group ID Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer group. May also be referred to as a Policy or Group ID group : : string [0..1] [0..1] Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer group. May also be referred to as a Policy or Group ID Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer group. May also be referred to as a Policy or Group ID plan : : string [0..1] [0..1] Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a specific employer group within a class of employers. May be referred to as a Section or Division ID Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a specific employer group within a class of employers. May be referred to as a Section or Division ID subPlan : : string [0..1] [0..1] A unique identifier for a dependent under the coverage A unique identifier for a dependent under the coverage dependent : : positiveInt [0..1] [0..1] An optional counter for a particular instance of the identified coverage which increments upon each renewal An optional counter for a particular instance of the identified coverage which increments upon each renewal sequence : : positiveInt [0..1] [0..1] The party who 'owns' the insurance contractual relationship to the policy or to whom the benefit of the policy is due (this element modifies the meaning of other elements) Factors which may influence the applicability of coverage subscriber : Reference [0..1] « Patient » exception : Coding [0..*] « The eligibility exception codes. (Strength=Example) Exception ?? » Name of school for over-aged dependants school : string [0..1] The identifier for a community of providers The identifier for a community of providers network : Identifier [0..1] : string [0..1] The policy(s) which constitute this insurance coverage The policy(s) which constitute this insurance coverage contract : : Reference [0..*] « [0..*] « Contract » »

XML Template XML Template 

<Coverage xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</issuer>
 <</bin>

 <issuer[x]><!-- 1..1 Identifier|Reference(Organization) Identifier for the plan issuer --></issuer[x]>
 <bin value="[string]"/><!-- 0..1 BIN Number -->

 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <</type>
 <</subscriberId>

 <type><!-- 0..1 Coding Type of coverage --></type>
 <planholder[x]><!-- 1..1 Identifier|Reference(Patient|Organization) Plan holder --></planholder[x]>
 <beneficiary[x]><!-- 1..1 Identifier|Reference(Patient) Plan Beneficiary --></beneficiary[x]>
 <relationship><!-- 1..1 Coding Patient relationship to planholder --></relationship>

 <identifier><!-- 0..* Identifier The primary coverage ID --></identifier>
 <group value="[string]"/><!-- 0..1 An identifier for the group -->
 <plan value="[string]"/><!-- 0..1 An identifier for the plan -->
 <subPlan value="[string]"/><!-- 0..1 An identifier for the subsection of the plan -->
 <

 <dependent value="[positiveInt]"/><!-- 0..1 Dependent number -->

 <sequence value="[positiveInt]"/><!-- 0..1 The plan instance or sequence counter -->
 <</subscriber>
 <</network>

 <exception><!-- 0..* Coding Eligibility exceptions --></exception>
 <school value="[string]"/><!-- 0..1 Name of School -->
 <network value="[string]"/><!-- 0..1 Insurer network -->

 <contract><!-- 0..* Reference(Contract) Contract details --></contract>
</Coverage>

JSON Template JSON Template

  Alternate definitions:

Alternate definitions: Schema / Schematron , Resource Profile ( , Resource Profile ( XML , , JSON ), ), Questionnaire

7.3.2.1 Terminology Bindings Terminology Bindings

Path Definition Type Reference
Coverage.type Coverage.type The type of insurance: public health, worker compensation; private accident, auto, private health, etc.). The type of insurance: public health, worker compensation; private accident, auto, private health, etc.). Example ActCoverageTypeCode
Coverage.relationship The code for the relationship of the patient to the subscriber. Example Beneficiary Relationship Codes
Coverage.exception The eligibility exception codes. Example Exception Codes

7.3.3 Search Parameters Search Parameters Search parameters for this resource. The common parameters also apply. See

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services. for more information about searching in REST, messaging, and services.

© HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100. Links: Search
Name Type Description Paths
beneficiaryidentifier token Covered party Coverage.beneficiaryIdentifier
beneficiaryreference reference Covered party Coverage.beneficiaryReference
( Patient )
dependent token Dependent number Dependent number Coverage.dependent
group token Group identifier Group identifier Coverage.group
identifier token The primary identifier of the insured The primary identifier of the insured and the coverage Coverage.identifier
issuer issueridentifier token The identity of the insurer Coverage.issuerIdentifier
issuerreference reference The identity of the insurer The identity of the insurer Coverage.issuer Coverage.issuerReference
( Organization )
plan token A plan or policy identifier A plan or policy identifier Coverage.plan
planholderidentifier token Reference to the planholder Coverage.planholderIdentifier
planholderreference reference Reference to the planholder Coverage.planholderReference
( Organization , Patient )
sequence token Sequence number Sequence number Coverage.sequence
subplan token Sub-plan identifier Sub-plan identifier Coverage.subPlan
type token The kind of coverage The kind of coverage (health plan, auto, Workers Compensation) Coverage.type