STU3 Candidate

This page is part of the FHIR Specification (v1.8.0: STU 3 Draft). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

13.3 Resource Coverage - Content

Financial Management Work Group Maturity Level : 1 Compartments : Not linked to any defined compartments

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

13.3.1 Scope and Usage

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

This resource may also be used to register 'SelfPay' where and individual or organization other than an insurer it taking responsibility for payment for a portion of the health care costs.

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

13.3.2 Resource Content

Structure

Name Flags Card. Type Description & Constraints doco
. . Coverage DomainResource Insurance or medical plan or a payment agreement
. . . identifier Σ 0..* Identifier The primary coverage ID
. . . status ?! Σ 0..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
. . . type Σ 0..1 CodeableConcept Type of coverage
Coverage Type 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..1 string ID assigned to the Subscriber
. . . beneficiary Σ 0..1 Reference ( Patient ) Plan Beneficiary
. . . relationship 0..1 CodeableConcept Beneficiary relationship to the Subscriber
Policyholder Relationship Codes ( Example )
. . . period Σ 0..1 Period Coverage start and end dates
. . . payor Σ 0..* Reference ( Organization | Patient | RelatedPerson ) Identifier for the plan or agreement issuer
. . . group 0..1 BackboneElement Additional coverage classifications
. . . . group Σ 0..1 string An identifier for the group
. . . . groupDisplay Σ 0..1 string Display text for an identifier for the group
. . . . subGroup Σ 0..1 string An identifier for the subsection of the group
. . . . subGroupDisplay Σ 0..1 string Display text for the subsection of the group
. . . . plan Σ 0..1 string An identifier for the plan
. . . . planDisplay Σ 0..1 string Display text for the plan
. . . . subPlan Σ 0..1 string An identifier for the subsection of the plan
. . . . subPlanDisplay Σ 0..1 string Display text for the subsection of the plan
. . . . class Σ 0..1 string An identifier for the class
. . . . classDisplay Σ 0..1 string Display text for the class
. . . . subClass Σ 0..1 string An identifier for the subsection of the class
. . . . subClassDisplay Σ 0..1 string Display text for the subsection of the subclass
. . . dependent Σ 0..1 string Dependent number
. . . sequence Σ 0..1 string The plan instance or sequence counter
. . . order Σ 0..1 positiveInt Relative order of the coverage
. . . network Σ 0..1 string Insurer network
. . . contract 0..* Reference ( Contract ) Contract details

doco Documentation for this format

UML Diagram ( Legend )

Coverage ( DomainResource ) The main (and possibly only) identifier for 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 the Coverage.dependant identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required) Financial Resource Status ! » 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. (Strength=Preferred) Coverage Type ? » The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer 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 [0..1] The party who benefits from the insurance coverage., the patient when services are provided beneficiary : Reference [0..1] « Patient » 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) Policyholder Relationship ?? » 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] 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 insurance company identifier or business identifier (BIN number) payor : Reference [0..*] « 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 sequence : string [0..1] The order of applicability of this coverage relative to other coverages which are currently inforce. Note, there may be gaps in the numbering and this does not imply primary, secondard etc. as the specific positioning of coverages depends upon the episode of care 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] The policy(s) which constitute this insurance coverage contract : Reference [0..*] « Contract » Group Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify an employer group. May also be referred to as a Policy or Group ID group : string [0..1] A short description for the group groupDisplay : string [0..1] Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a subset of an employer group subGroup : string [0..1] A short description for the subgroup subGroupDisplay : string [0..1] Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a collection of benefits provided to employees. May be referred to as a Section or Division ID plan : string [0..1] A short description for the plan planDisplay : string [0..1] Identifies a sub-style or sub-collective of coverage issued by the underwriter, for example may be used to identify a subset of a collection of benefits provided to employees subPlan : string [0..1] A short description for the subplan subPlanDisplay : string [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 class : string [0..1] A short description for the class classDisplay : string [0..1] Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a subclass of coverage or employer group subClass : string [0..1] A short description for the subclass subClassDisplay : string [0..1] A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan group [0..1]

XML Template 

<Coverage xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier The primary coverage ID --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Type of coverage --></type>
 <policyHolder><!-- 0..1 Reference(Patient|RelatedPerson|Organization) Owner of the policy --></policyHolder>
 <subscriber><!-- 0..1 Reference(Patient|RelatedPerson) Subscriber to the policy --></subscriber>
 <subscriberId value="[string]"/><!-- 0..1 ID assigned to the Subscriber -->
 <beneficiary><!-- 0..1 Reference(Patient) Plan Beneficiary --></beneficiary>
 <relationship><!-- 0..1 CodeableConcept Beneficiary relationship to the Subscriber --></relationship>
 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <payor><!-- 0..* Reference(Organization|Patient|RelatedPerson) Identifier for the plan or agreement issuer --></payor>
 <group>  <!-- 0..1 Additional coverage classifications -->
  <group value="[string]"/><!-- 0..1 An identifier for the group -->
  <groupDisplay value="[string]"/><!-- 0..1 Display text for an identifier for the group -->
  <subGroup value="[string]"/><!-- 0..1 An identifier for the subsection of the group -->
  <subGroupDisplay value="[string]"/><!-- 0..1 Display text for the subsection of the group -->
  <plan value="[string]"/><!-- 0..1 An identifier for the plan -->
  <planDisplay value="[string]"/><!-- 0..1 Display text for the plan -->
  <subPlan value="[string]"/><!-- 0..1 An identifier for the subsection of the plan -->
  <subPlanDisplay value="[string]"/><!-- 0..1 Display text for the subsection of the plan -->
  <class value="[string]"/><!-- 0..1 An identifier for the class -->
  <classDisplay value="[string]"/><!-- 0..1 Display text for the class -->
  <subClass value="[string]"/><!-- 0..1 An identifier for the subsection of the class -->
  <subClassDisplay value="[string]"/><!-- 0..1 Display text for the subsection of the subclass -->
 </group>
 <dependent value="[string]"/><!-- 0..1 Dependent number -->
 <sequence value="[string]"/><!-- 0..1 The plan instance or sequence counter -->
 <order value="[positiveInt]"/><!-- 0..1 Relative order of the coverage -->
 <network value="[string]"/><!-- 0..1 Insurer network -->
 <contract><!-- 0..* Reference(Contract) Contract details --></contract>
</Coverage>

JSON Template 

{doco
  "resourceType" : "Coverage",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // The primary coverage ID
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Type of coverage
  "policyHolder" : { Reference(Patient|RelatedPerson|Organization) }, // Owner of the policy
  "subscriber" : { Reference(Patient|RelatedPerson) }, // Subscriber to the policy
  "subscriberId" : "<string>", // ID assigned to the Subscriber
  "beneficiary" : { Reference(Patient) }, // Plan Beneficiary
  "relationship" : { CodeableConcept }, // Beneficiary relationship to the Subscriber
  "period" : { Period }, // Coverage start and end dates
  "payor" : [{ Reference(Organization|Patient|RelatedPerson) }], // Identifier for the plan or agreement issuer
  "group" : { // Additional coverage classifications
    "group" : "<string>", // An identifier for the group
    "groupDisplay" : "<string>", // Display text for an identifier for the group
    "subGroup" : "<string>", // An identifier for the subsection of the group
    "subGroupDisplay" : "<string>", // Display text for the subsection of the group
    "plan" : "<string>", // An identifier for the plan
    "planDisplay" : "<string>", // Display text for the plan
    "subPlan" : "<string>", // An identifier for the subsection of the plan
    "subPlanDisplay" : "<string>", // Display text for the subsection of the plan
    "class" : "<string>", // An identifier for the class
    "classDisplay" : "<string>", // Display text for the class
    "subClass" : "<string>", // An identifier for the subsection of the class
    "subClassDisplay" : "<string>" // Display text for the subsection of the subclass
  },
  "dependent" : "<string>", // Dependent number
  "sequence" : "<string>", // The plan instance or sequence counter
  "order" : "<positiveInt>", // Relative order of the coverage
  "network" : "<string>", // Insurer network
  "contract" : [{ Reference(Contract) }] // Contract details
}

Turtle Template 

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Coverage.identifier [ Identifier ], ... ; # 0..* The primary coverage ID
  fhir:Coverage.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:Coverage.type [ CodeableConcept ]; # 0..1 Type of coverage
  fhir:Coverage.policyHolder [ Reference(Patient|RelatedPerson|Organization) ]; # 0..1 Owner of the policy
  fhir:Coverage.subscriber [ Reference(Patient|RelatedPerson) ]; # 0..1 Subscriber to the policy
  fhir:Coverage.subscriberId [ string ]; # 0..1 ID assigned to the Subscriber
  fhir:Coverage.beneficiary [ Reference(Patient) ]; # 0..1 Plan Beneficiary
  fhir:Coverage.relationship [ CodeableConcept ]; # 0..1 Beneficiary relationship to the Subscriber
  fhir:Coverage.period [ Period ]; # 0..1 Coverage start and end dates
  fhir:Coverage.payor [ Reference(Organization|Patient|RelatedPerson) ], ... ; # 0..* Identifier for the plan or agreement issuer
  fhir:Coverage.group [ # 0..1 Additional coverage classifications
    fhir:Coverage.group.group [ string ]; # 0..1 An identifier for the group
    fhir:Coverage.group.groupDisplay [ string ]; # 0..1 Display text for an identifier for the group
    fhir:Coverage.group.subGroup [ string ]; # 0..1 An identifier for the subsection of the group
    fhir:Coverage.group.subGroupDisplay [ string ]; # 0..1 Display text for the subsection of the group
    fhir:Coverage.group.plan [ string ]; # 0..1 An identifier for the plan
    fhir:Coverage.group.planDisplay [ string ]; # 0..1 Display text for the plan
    fhir:Coverage.group.subPlan [ string ]; # 0..1 An identifier for the subsection of the plan
    fhir:Coverage.group.subPlanDisplay [ string ]; # 0..1 Display text for the subsection of the plan
    fhir:Coverage.group.class [ string ]; # 0..1 An identifier for the class
    fhir:Coverage.group.classDisplay [ string ]; # 0..1 Display text for the class
    fhir:Coverage.group.subClass [ string ]; # 0..1 An identifier for the subsection of the class
    fhir:Coverage.group.subClassDisplay [ string ]; # 0..1 Display text for the subsection of the subclass
  ];
  fhir:Coverage.dependent [ string ]; # 0..1 Dependent number
  fhir:Coverage.sequence [ string ]; # 0..1 The plan instance or sequence counter
  fhir:Coverage.order [ positiveInt ]; # 0..1 Relative order of the coverage
  fhir:Coverage.network [ string ]; # 0..1 Insurer network
  fhir:Coverage.contract [ Reference(Contract) ], ... ; # 0..* Contract details
]

Changes since DSTU2

Coverage
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 added Element
Coverage.group Type changed from string to BackboneElement
Coverage.group.group added Element
Coverage.group.groupDisplay added Element
Coverage.group.subGroup added Element
Coverage.group.subGroupDisplay added Element
Coverage.group.plan added Element
Coverage.group.planDisplay added Element
Coverage.group.subPlan added Element
Coverage.group.subPlanDisplay added Element
Coverage.group.class added Element
Coverage.group.classDisplay added Element
Coverage.group.subClass added Element
Coverage.group.subClassDisplay added Element
Coverage.dependent Type changed from positiveInt to string
Coverage.sequence Type changed from positiveInt to string
Coverage.order added Element
Coverage.network Type changed from Identifier to string
Coverage.issuer deleted
Coverage.bin deleted
Coverage.plan deleted
Coverage.subPlan deleted

See the Full Difference for further information

Structure

Name Flags Card. Type Description & Constraints doco
. . Coverage DomainResource Insurance or medical plan or a payment agreement
. . . identifier Σ 0..* Identifier The primary coverage ID
. . . status ?! Σ 0..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
. . . type Σ 0..1 CodeableConcept Type of coverage
Coverage Type 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..1 string ID assigned to the Subscriber
. . . beneficiary Σ 0..1 Reference ( Patient ) Plan Beneficiary
. . . relationship 0..1 CodeableConcept Beneficiary relationship to the Subscriber
Policyholder Relationship Codes ( Example )
. . . period Σ 0..1 Period Coverage start and end dates
. . . payor Σ 0..* Reference ( Organization | Patient | RelatedPerson ) Identifier for the plan or agreement issuer
. . . group 0..1 BackboneElement Additional coverage classifications
. . . . group Σ 0..1 string An identifier for the group
. . . . groupDisplay Σ 0..1 string Display text for an identifier for the group
. . . . subGroup Σ 0..1 string An identifier for the subsection of the group
. . . . subGroupDisplay Σ 0..1 string Display text for the subsection of the group
. . . . plan Σ 0..1 string An identifier for the plan
. . . . planDisplay Σ 0..1 string Display text for the plan
. . . . subPlan Σ 0..1 string An identifier for the subsection of the plan
. . . . subPlanDisplay Σ 0..1 string Display text for the subsection of the plan
. . . . class Σ 0..1 string An identifier for the class
. . . . classDisplay Σ 0..1 string Display text for the class
. . . . subClass Σ 0..1 string An identifier for the subsection of the class
. . . . subClassDisplay Σ 0..1 string Display text for the subsection of the subclass
. . . dependent Σ 0..1 string Dependent number
. . . sequence Σ 0..1 string The plan instance or sequence counter
. . . order Σ 0..1 positiveInt Relative order of the coverage
. . . network Σ 0..1 string Insurer network
. . . contract 0..* Reference ( Contract ) Contract details

doco Documentation for this format

UML Diagram ( Legend )

Coverage ( DomainResource ) The main (and possibly only) identifier for 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 the Coverage.dependant identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required) Financial Resource Status ! » 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. (Strength=Preferred) Coverage Type ? » The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer 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 [0..1] The party who benefits from the insurance coverage., the patient when services are provided beneficiary : Reference [0..1] « Patient » 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) Policyholder Relationship ?? » 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] 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 insurance company identifier or business identifier (BIN number) payor : Reference [0..*] « 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 sequence : string [0..1] The order of applicability of this coverage relative to other coverages which are currently inforce. Note, there may be gaps in the numbering and this does not imply primary, secondard etc. as the specific positioning of coverages depends upon the episode of care 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] The policy(s) which constitute this insurance coverage contract : Reference [0..*] « Contract » Group Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify an employer group. May also be referred to as a Policy or Group ID group : string [0..1] A short description for the group groupDisplay : string [0..1] Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a subset of an employer group subGroup : string [0..1] A short description for the subgroup subGroupDisplay : string [0..1] Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a collection of benefits provided to employees. May be referred to as a Section or Division ID plan : string [0..1] A short description for the plan planDisplay : string [0..1] Identifies a sub-style or sub-collective of coverage issued by the underwriter, for example may be used to identify a subset of a collection of benefits provided to employees subPlan : string [0..1] A short description for the subplan subPlanDisplay : string [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 class : string [0..1] A short description for the class classDisplay : string [0..1] Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a subclass of coverage or employer group subClass : string [0..1] A short description for the subclass subClassDisplay : string [0..1] A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan group [0..1]

XML Template 

<Coverage xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier The primary coverage ID --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Type of coverage --></type>
 <policyHolder><!-- 0..1 Reference(Patient|RelatedPerson|Organization) Owner of the policy --></policyHolder>
 <subscriber><!-- 0..1 Reference(Patient|RelatedPerson) Subscriber to the policy --></subscriber>
 <subscriberId value="[string]"/><!-- 0..1 ID assigned to the Subscriber -->
 <beneficiary><!-- 0..1 Reference(Patient) Plan Beneficiary --></beneficiary>
 <relationship><!-- 0..1 CodeableConcept Beneficiary relationship to the Subscriber --></relationship>
 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <payor><!-- 0..* Reference(Organization|Patient|RelatedPerson) Identifier for the plan or agreement issuer --></payor>
 <group>  <!-- 0..1 Additional coverage classifications -->
  <group value="[string]"/><!-- 0..1 An identifier for the group -->
  <groupDisplay value="[string]"/><!-- 0..1 Display text for an identifier for the group -->
  <subGroup value="[string]"/><!-- 0..1 An identifier for the subsection of the group -->
  <subGroupDisplay value="[string]"/><!-- 0..1 Display text for the subsection of the group -->
  <plan value="[string]"/><!-- 0..1 An identifier for the plan -->
  <planDisplay value="[string]"/><!-- 0..1 Display text for the plan -->
  <subPlan value="[string]"/><!-- 0..1 An identifier for the subsection of the plan -->
  <subPlanDisplay value="[string]"/><!-- 0..1 Display text for the subsection of the plan -->
  <class value="[string]"/><!-- 0..1 An identifier for the class -->
  <classDisplay value="[string]"/><!-- 0..1 Display text for the class -->
  <subClass value="[string]"/><!-- 0..1 An identifier for the subsection of the class -->
  <subClassDisplay value="[string]"/><!-- 0..1 Display text for the subsection of the subclass -->
 </group>
 <dependent value="[string]"/><!-- 0..1 Dependent number -->
 <sequence value="[string]"/><!-- 0..1 The plan instance or sequence counter -->
 <order value="[positiveInt]"/><!-- 0..1 Relative order of the coverage -->
 <network value="[string]"/><!-- 0..1 Insurer network -->
 <contract><!-- 0..* Reference(Contract) Contract details --></contract>
</Coverage>

JSON Template 

{doco
  "resourceType" : "Coverage",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // The primary coverage ID
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Type of coverage
  "policyHolder" : { Reference(Patient|RelatedPerson|Organization) }, // Owner of the policy
  "subscriber" : { Reference(Patient|RelatedPerson) }, // Subscriber to the policy
  "subscriberId" : "<string>", // ID assigned to the Subscriber
  "beneficiary" : { Reference(Patient) }, // Plan Beneficiary
  "relationship" : { CodeableConcept }, // Beneficiary relationship to the Subscriber
  "period" : { Period }, // Coverage start and end dates
  "payor" : [{ Reference(Organization|Patient|RelatedPerson) }], // Identifier for the plan or agreement issuer
  "group" : { // Additional coverage classifications
    "group" : "<string>", // An identifier for the group
    "groupDisplay" : "<string>", // Display text for an identifier for the group
    "subGroup" : "<string>", // An identifier for the subsection of the group
    "subGroupDisplay" : "<string>", // Display text for the subsection of the group
    "plan" : "<string>", // An identifier for the plan
    "planDisplay" : "<string>", // Display text for the plan
    "subPlan" : "<string>", // An identifier for the subsection of the plan
    "subPlanDisplay" : "<string>", // Display text for the subsection of the plan
    "class" : "<string>", // An identifier for the class
    "classDisplay" : "<string>", // Display text for the class
    "subClass" : "<string>", // An identifier for the subsection of the class
    "subClassDisplay" : "<string>" // Display text for the subsection of the subclass
  },
  "dependent" : "<string>", // Dependent number
  "sequence" : "<string>", // The plan instance or sequence counter
  "order" : "<positiveInt>", // Relative order of the coverage
  "network" : "<string>", // Insurer network
  "contract" : [{ Reference(Contract) }] // Contract details
}

Turtle Template 

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Coverage.identifier [ Identifier ], ... ; # 0..* The primary coverage ID
  fhir:Coverage.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:Coverage.type [ CodeableConcept ]; # 0..1 Type of coverage
  fhir:Coverage.policyHolder [ Reference(Patient|RelatedPerson|Organization) ]; # 0..1 Owner of the policy
  fhir:Coverage.subscriber [ Reference(Patient|RelatedPerson) ]; # 0..1 Subscriber to the policy
  fhir:Coverage.subscriberId [ string ]; # 0..1 ID assigned to the Subscriber
  fhir:Coverage.beneficiary [ Reference(Patient) ]; # 0..1 Plan Beneficiary
  fhir:Coverage.relationship [ CodeableConcept ]; # 0..1 Beneficiary relationship to the Subscriber
  fhir:Coverage.period [ Period ]; # 0..1 Coverage start and end dates
  fhir:Coverage.payor [ Reference(Organization|Patient|RelatedPerson) ], ... ; # 0..* Identifier for the plan or agreement issuer
  fhir:Coverage.group [ # 0..1 Additional coverage classifications
    fhir:Coverage.group.group [ string ]; # 0..1 An identifier for the group
    fhir:Coverage.group.groupDisplay [ string ]; # 0..1 Display text for an identifier for the group
    fhir:Coverage.group.subGroup [ string ]; # 0..1 An identifier for the subsection of the group
    fhir:Coverage.group.subGroupDisplay [ string ]; # 0..1 Display text for the subsection of the group
    fhir:Coverage.group.plan [ string ]; # 0..1 An identifier for the plan
    fhir:Coverage.group.planDisplay [ string ]; # 0..1 Display text for the plan
    fhir:Coverage.group.subPlan [ string ]; # 0..1 An identifier for the subsection of the plan
    fhir:Coverage.group.subPlanDisplay [ string ]; # 0..1 Display text for the subsection of the plan
    fhir:Coverage.group.class [ string ]; # 0..1 An identifier for the class
    fhir:Coverage.group.classDisplay [ string ]; # 0..1 Display text for the class
    fhir:Coverage.group.subClass [ string ]; # 0..1 An identifier for the subsection of the class
    fhir:Coverage.group.subClassDisplay [ string ]; # 0..1 Display text for the subsection of the subclass
  ];
  fhir:Coverage.dependent [ string ]; # 0..1 Dependent number
  fhir:Coverage.sequence [ string ]; # 0..1 The plan instance or sequence counter
  fhir:Coverage.order [ positiveInt ]; # 0..1 Relative order of the coverage
  fhir:Coverage.network [ string ]; # 0..1 Insurer network
  fhir:Coverage.contract [ Reference(Contract) ], ... ; # 0..* Contract details
]

Changes since DSTU2

Coverage
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 added Element
Coverage.group Type changed from string to BackboneElement
Coverage.group.group added Element
Coverage.group.groupDisplay added Element
Coverage.group.subGroup added Element
Coverage.group.subGroupDisplay added Element
Coverage.group.plan added Element
Coverage.group.planDisplay added Element
Coverage.group.subPlan added Element
Coverage.group.subPlanDisplay added Element
Coverage.group.class added Element
Coverage.group.classDisplay added Element
Coverage.group.subClass added Element
Coverage.group.subClassDisplay added Element
Coverage.dependent Type changed from positiveInt to string
Coverage.sequence Type changed from positiveInt to string
Coverage.order added Element
Coverage.network Type changed from Identifier to string
Coverage.issuer deleted
Coverage.bin deleted
Coverage.plan deleted
Coverage.subPlan deleted

See the Full Difference for further information

 

Alternate definitions: Master Definition ( XML , JSON ), XML Schema / Schematron (for ) + JSON Schema , ShEx (for Turtle ), JSON-LD (for RDF as JSON-LD ),

13.3.2.1 Terminology Bindings

Path Definition Type Reference
Coverage.status A code specifying the state of the resource instance. Required Financial Resource Status Codes
Coverage.type The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. Preferred Coverage Type Codes
Coverage.relationship The relationship between the Policyholder and the Beneficiary (insured/covered party/patient). Example Policyholder Relationship Codes

13.3.3 Search Parameters

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

Name Type Description Paths In Common
beneficiary reference Covered party Coverage.beneficiary
( Patient )
class string Class identifier Coverage.group.class
dependent string Dependent number Coverage.dependent
group string Group identifier Coverage.group.group
identifier token The primary identifier of the insured and the coverage Coverage.identifier
payor reference The identity of the insurer or party paying for services Coverage.payor
( Organization , Patient , RelatedPerson )
plan string A plan or policy identifier Coverage.group.plan
policyholder reference Reference to the policyholder Coverage.policyHolder
( Organization , Patient , RelatedPerson )
sequence string Sequence number Coverage.sequence
subclass string Sub-class identifier Coverage.group.subClass
subgroup string Sub-group identifier Coverage.group.subGroup
subplan string Sub-plan identifier Coverage.group.subPlan
subscriber reference Reference to the subscriber Coverage.subscriber
( Patient , RelatedPerson )
type token The kind of coverage (health plan, auto, Workers Compensation) Coverage.type