DSTU2 STU 3 Ballot
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This page is part of the FHIR Specification (v1.6.0: STU 3 Ballot 4). 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

7.3.5 13.3.5 Resource Coverage - Detailed Descriptions Resource Coverage - Detailed Descriptions Detailed Descriptions for the elements in the Coverage resource.

Detailed Descriptions for the elements in the Coverage resource.

© HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100. Links: Search | Version History | Table of Contents | Compare to DSTU1
Coverage
Definition

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

Control 1..1
Requirements

Health care programs and insurers are significant payors of health service costs. Health care programs and insurers are significant payors of health service costs.

Coverage.issuer Coverage.status
Definition

The program or plan underwriter or payor. The status of the resource instance.

Control 1..1
Binding CoverageStatus: A code specifying the state of the resource instance. ( Required )
Type code
Is Modifier true
Summary true
Coverage.issuer[x]
Definition

The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.

Control 0..1 1..1
Type Identifier | Reference ( Organization | Patient | RelatedPerson )
[x] Note See Choice of Data Types for further information about how to use [x]
Requirements

Need to identify the issuer to target for processing and for coordination of benefit processing. Need to identify the issuer to target for processing and for coordination of benefit processing.

Summary true
Coverage.isAgreement
Definition

A self, or other, payment agreement not an insurance policy.

Control 0..1
Type boolean
Requirements

Only insurance policies receive Claims, agreements receive bills.

Summary true
Coverage.bin
Definition

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.

Control 0..1
Type Identifier string
Summary true
Coverage.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. 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.

Control 0..1
Type Period
Summary true
Coverage.type
Definition

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.

Control 0..1
Binding ActCoverageTypeCode: The type of insurance: public health, worker compensation; private accident, auto, private health, etc.). ( ActCoverageTypeCode: The type of insurance: public health, worker compensation; private accident, auto, private health, etc.). ( Example )
Type Coding
Requirements

The order of application of coverages is dependent on the types of coverage. The order of application of coverages is dependent on the types of coverage.

Summary true
Coverage.subscriberId Coverage.planholder[x]
Definition

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.

Control 1..1
Type Identifier | Reference ( Patient | Organization )
[x] Note See Choice of Data Types for further information about how to use [x]
Summary true
To Do D01 through D09.
Coverage.beneficiary[x]
Definition

The party who benefits from the insurance coverage.

Control 0..1 1..1
Type Identifier | Reference ( Patient )
[x] Note See Choice of Data Types for further information about how to use [x]
Summary true
To Do D01 through D09.
Coverage.relationship
Definition

The relationship of beneficiary (patient) (subscriber) to the the planholder.

Control 1..1
Binding Policyholder Relationship Codes: The relationship between the Policyholder and the Beneficiary (insured/covered party/patient). ( Example )
Type Coding
Requirements

To determine relationship between the patient and the subscriber.

Coverage.identifier
Definition

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.

Note This is a business identifer, not a resource identifier (see This is a business identifer, not a resource identifier (see discussion )
Control 0..*
Type Identifier
Requirements

This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below. This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below.

Summary true
Coverage.group
Definition

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.

Control 0..1
Type string
Summary true
Coverage.plan Coverage.subGroup
Definition

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.

Control 0..1
Type string
Summary true
Coverage.subPlan Coverage.plan
Definition

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 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.

Control 0..1
Type string
Summary true
Coverage.dependent Coverage.subPlan
Definition

A unique identifier for a dependent under the coverage. 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.

Control 0..1
Type positiveInt string
Requirements Summary true
Coverage.class
Definition

For some coverage a single identifier is issued to the PolicyHolder and dependent number issues to each to each of their dependents to track and manage the plan. 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.

Control 0..1
Type string
Summary true
Coverage.sequence Coverage.dependent
Definition

An optional counter for a particular instance of the identified coverage which increments upon each renewal. A unique identifier for a dependent under the coverage.

Control 0..1
Type positiveInt
Requirements

Some coverage, for example social plans, may be offered in short time increments, for example for a week or a month at a time, so while the rest of the plan details and identifiers may remain constant over time, the instance is incremented with each renewal and provided to the covered party on their 'card'. For some coverage a single identifier is issued to the PolicyHolder and a dependent number issued to each beneficiary.

Summary true
Coverage.subscriber Coverage.sequence
Definition

The party who 'owns' the insurance contractual relationship to the policy or to whom the benefit of the policy is due. An optional counter for a particular instance of the identified coverage which increments upon each renewal.

Control 0..1
Type Reference ( Patient positiveInt )
Is Modifier Requirements true

Some coverage, for example social plans, may be offered in short time increments, for example for a week or a month at a time, so while the rest of the plan details and identifiers may remain constant over time, the instance is incremented with each renewal and provided to the covered party on their 'card'.

To Do Summary D01 through D09. true
Coverage.network
Definition

The identifier for a community of providers. The identifier for a community of providers.

Control 0..1
Type Identifier string
Summary true
Coverage.contract
Definition

The policy(s) which constitute this insurance coverage. The policy(s) which constitute this insurance coverage.

Control 0..*
Type Reference ( Contract )
To Do To Do D01 through D09. D01 through D09.