|
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.
|
©
HL7.org
2011+.
FHIR
DSTU2
(v1.0.2-7202)
generated
on
Sat,
Oct
24,
2015
07:43+1100.
Links:
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