R4 Ballot #1 #2 (Mixed Normative/Trial use)

This page is part of the FHIR Specification (v3.3.0: (v3.5.0: R4 Ballot 2). #2). 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

13.1 Resource Coverage - Content

Financial Management Work Group Maturity Level : 2   Trial Use Compartments : Patient , RelatedPerson

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

13.1.1 Scope and Usage

The Coverage resource is intended to provide the high level high-level identifiers and 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.

This resource is referenced by Account , Claim , ClaimResponse , DeviceRequest CoverageEligibilityRequest , EligibilityRequest CoverageEligibilityResponse , EligibilityResponse DeviceRequest , EnrollmentRequest , ExplanationOfBenefit , MedicationRequest , ServiceRequest and ServiceRequest Task

13.1.2 Resource Content

Structure

Name Flags Card. Type Description & Constraints doco
. . Coverage TU 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 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 such as medical or accident
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..1 string ID assigned to the Subscriber
. . . beneficiary Σ 0..1 Reference ( Patient ) Plan Beneficiary
. . . dependent Σ 0..1 string Dependent number
. . . 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
. . . class 0..* BackboneElement Additional coverage classifications
. . . . type Σ 1..1 Coding Type of class such as 'group' or 'plan'
Coverage Class Codes ( Extensible )
. . . . value Σ 1..1 string The tag or value under the classification
. . . . name Σ 0..1 string Display text for an identifier for the group
. . . order Σ 0..1 positiveInt Relative order of the coverage
. . . network Σ 0..1 string Insurer network
. . . copay 0..* BackboneElement Patient payments for services/products
. . . . type Σ 0..1 Coding The type of service or product
Coverage Copay Type Codes ( Extensible )
. . . . value Σ 1..1 Quantity The amount or percentage of the copayment
. . . 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 concatenation 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 FinancialResourceStatusCodes ! » 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 and Self-Pay CoverageTypeAndSelf-PayCodes ? » 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., coverage; the patient when services are provided beneficiary : Reference [0..1] « Patient » A unique identifier 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) Policyholder Relationship PolicyholderRelationshipCodes ?? » 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 » 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 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 » Class The type of classification for which an insurer-specific class tag or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan type : Coding [1..1] « The policy classifications, eg. Group, Plan, Class, etc. (Strength=Extensible) Coverage Class CoverageClassCodes + » For example example, the Group or Plan number value : string [1..1] A short description for the class name : string [0..1] CoPay Types of products or services such as visit, specialist vists, visits, emergency, inpatient care, etc type : Coding [0..1] « The tytpes of services to which patient copayments are specified. (Strength=Extensible) Coverage Copay Type CoverageCopayTypeCodes + » The amount of patient payments for various types of services/products, expressed as a percentage of the service/product cost or a fixed amount of currency, currency value : Quantity [1..1] A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan class [0..*] A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan copay [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>

 <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 such as medical or accident --></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>

 <beneficiary><!-- 0..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>
 <payor><!-- 0..* Reference(Organization|Patient|RelatedPerson) Identifier for the plan or agreement issuer --></payor>
 <class>  <!-- 0..* Additional coverage classifications -->
  <type><!-- 1..1 Coding Type of class such as 'group' or 'plan' --></type>
  <

  <value value="[string]"/><!-- 1..1 The tag or value under the classification -->

  <name value="[string]"/><!-- 0..1 Display text for an identifier for the group -->
 </class>
 <

 <order value="[positiveInt]"/><!-- 0..1 Relative order of the coverage -->

 <network value="[string]"/><!-- 0..1 Insurer network -->
 <copay>  <!-- 0..* Patient payments for services/products -->
  <</type>
  <</value>

  <type><!-- 0..1 Coding The type of service or product --></type>
  <value><!-- 1..1 Quantity The amount or percentage of the copayment --></value>

 </copay>
 <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 such as medical or accident
  "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

  "dependent" : "<string>", // Dependent number
  "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
  "class" : [{ // Additional coverage classifications
    "type" : { Coding }, // R!  Type of class such as 'group' or 'plan'
    "

    "value" : "<string>", // R!  The tag or value under the classification

    "name" : "<string>" // Display text for an identifier for the group
  }],
  "

  "order" : "<positiveInt>", // Relative order of the coverage

  "network" : "<string>", // Insurer network
  "copay" : [{ // Patient payments for services/products
    "
    "

    "type" : { Coding }, // The type of service or product
    "value" : { Quantity } // R!  The amount or percentage of the copayment

  }],
  "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:

  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 such as medical or accident
  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:

  fhir:Coverage.beneficiary [ Reference(Patient) ]; # 0..1 Plan Beneficiary

  fhir:Coverage.dependent [ string ]; # 0..1 Dependent number
  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.class [ # 0..* Additional coverage classifications
    fhir:Coverage.class.type [ Coding ]; # 1..1 Type of class such as 'group' or 'plan'
    fhir:

    fhir:Coverage.class.value [ string ]; # 1..1 The tag or value under the classification

    fhir:Coverage.class.name [ string ]; # 0..1 Display text for an identifier for the group
  ], ...;
  fhir:

  fhir:Coverage.order [ positiveInt ]; # 0..1 Relative order of the coverage

  fhir:Coverage.network [ string ]; # 0..1 Insurer network
  fhir:Coverage.copay [ # 0..* Patient payments for services/products
    fhir:
    fhir:

    fhir:Coverage.copay.type [ Coding ]; # 0..1 The type of service or product
    fhir:Coverage.copay.value [ Quantity ]; # 1..1 The amount or percentage of the copayment

  ], ...;
  fhir:Coverage.contract [ Reference(Contract) ], ... ; # 0..* Contract details
]

Changes since R3

Coverage
Coverage.class
  • Added Element
Coverage.class.type
  • Added Element
Coverage.class.value
  • Added Element
Coverage.class.name
  • Added Element
Coverage.copay
  • Added Element
Coverage.copay.type
  • Added Element
Coverage.copay.value
  • Added Element
Coverage.grouping
  • deleted
Coverage.sequence
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

See R3 <--> R4 Conversion Maps (status = 4 tests of which 4 fail to execute .)

Structure

Name Flags Card. Type Description & Constraints doco
. . Coverage TU 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 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 such as medical or accident
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..1 string ID assigned to the Subscriber
. . . beneficiary Σ 0..1 Reference ( Patient ) Plan Beneficiary
. . . dependent Σ 0..1 string Dependent number
. . . 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
. . . class 0..* BackboneElement Additional coverage classifications
. . . . type Σ 1..1 Coding Type of class such as 'group' or 'plan'
Coverage Class Codes ( Extensible )
. . . . value Σ 1..1 string The tag or value under the classification
. . . . name Σ 0..1 string Display text for an identifier for the group
. . . order Σ 0..1 positiveInt Relative order of the coverage
. . . network Σ 0..1 string Insurer network
. . . copay 0..* BackboneElement Patient payments for services/products
. . . . type Σ 0..1 Coding The type of service or product
Coverage Copay Type Codes ( Extensible )
. . . . value Σ 1..1 Quantity The amount or percentage of the copayment
. . . 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 concatenation 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 FinancialResourceStatusCodes ! » 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 and Self-Pay CoverageTypeAndSelf-PayCodes ? » 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., coverage; the patient when services are provided beneficiary : Reference [0..1] « Patient » A unique identifier 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) Policyholder Relationship PolicyholderRelationshipCodes ?? » 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 » 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 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 » Class The type of classification for which an insurer-specific class tag or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan type : Coding [1..1] « The policy classifications, eg. Group, Plan, Class, etc. (Strength=Extensible) Coverage Class CoverageClassCodes + » For example example, the Group or Plan number value : string [1..1] A short description for the class name : string [0..1] CoPay Types of products or services such as visit, specialist vists, visits, emergency, inpatient care, etc type : Coding [0..1] « The tytpes of services to which patient copayments are specified. (Strength=Extensible) Coverage Copay Type CoverageCopayTypeCodes + » The amount of patient payments for various types of services/products, expressed as a percentage of the service/product cost or a fixed amount of currency, currency value : Quantity [1..1] A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan class [0..*] A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan copay [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>

 <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 such as medical or accident --></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>

 <beneficiary><!-- 0..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>
 <payor><!-- 0..* Reference(Organization|Patient|RelatedPerson) Identifier for the plan or agreement issuer --></payor>
 <class>  <!-- 0..* Additional coverage classifications -->
  <type><!-- 1..1 Coding Type of class such as 'group' or 'plan' --></type>
  <

  <value value="[string]"/><!-- 1..1 The tag or value under the classification -->

  <name value="[string]"/><!-- 0..1 Display text for an identifier for the group -->
 </class>
 <

 <order value="[positiveInt]"/><!-- 0..1 Relative order of the coverage -->

 <network value="[string]"/><!-- 0..1 Insurer network -->
 <copay>  <!-- 0..* Patient payments for services/products -->
  <</type>
  <</value>

  <type><!-- 0..1 Coding The type of service or product --></type>
  <value><!-- 1..1 Quantity The amount or percentage of the copayment --></value>

 </copay>
 <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 such as medical or accident
  "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

  "dependent" : "<string>", // Dependent number
  "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
  "class" : [{ // Additional coverage classifications
    "type" : { Coding }, // R!  Type of class such as 'group' or 'plan'
    "

    "value" : "<string>", // R!  The tag or value under the classification

    "name" : "<string>" // Display text for an identifier for the group
  }],
  "

  "order" : "<positiveInt>", // Relative order of the coverage

  "network" : "<string>", // Insurer network
  "copay" : [{ // Patient payments for services/products
    "
    "

    "type" : { Coding }, // The type of service or product
    "value" : { Quantity } // R!  The amount or percentage of the copayment

  }],
  "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:

  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 such as medical or accident
  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:

  fhir:Coverage.beneficiary [ Reference(Patient) ]; # 0..1 Plan Beneficiary

  fhir:Coverage.dependent [ string ]; # 0..1 Dependent number
  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.class [ # 0..* Additional coverage classifications
    fhir:Coverage.class.type [ Coding ]; # 1..1 Type of class such as 'group' or 'plan'
    fhir:

    fhir:Coverage.class.value [ string ]; # 1..1 The tag or value under the classification

    fhir:Coverage.class.name [ string ]; # 0..1 Display text for an identifier for the group
  ], ...;
  fhir:

  fhir:Coverage.order [ positiveInt ]; # 0..1 Relative order of the coverage

  fhir:Coverage.network [ string ]; # 0..1 Insurer network
  fhir:Coverage.copay [ # 0..* Patient payments for services/products
    fhir:
    fhir:

    fhir:Coverage.copay.type [ Coding ]; # 0..1 The type of service or product
    fhir:Coverage.copay.value [ Quantity ]; # 1..1 The amount or percentage of the copayment

  ], ...;
  fhir:Coverage.contract [ Reference(Contract) ], ... ; # 0..* Contract details
]

Changes since DSTU2 Release 3

Coverage
Coverage.class
  • Added Element
Coverage.class.type
  • Added Element
Coverage.class.value
  • Added Element
Coverage.class.name
  • Added Element
Coverage.copay
  • Added Element
Coverage.copay.type
  • Added Element
Coverage.copay.value
  • Added Element
Coverage.grouping
  • deleted
Coverage.sequence
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

See R3 <--> R4 Conversion Maps (status = 4 tests of which 4 fail to execute .)

 

Alternate See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON , XML Schema / Schematron + JSON Schema , ShEx (for Turtle ) + see the extensions & the dependency analysis

13.1.2.1 Terminology Bindings

Path Definition Type Reference
Coverage.status A code specifying the state of the resource instance. Required Financial Resource Status Codes FinancialResourceStatusCodes
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 and Self-Pay Codes CoverageTypeAndSelf-PayCodes
Coverage.relationship The relationship between the Policyholder and the Beneficiary (insured/covered party/patient). Example Policyholder Relationship Codes PolicyholderRelationshipCodes
Coverage.class.type The policy classifications, eg. Group, Plan, Class, etc. Extensible Coverage Class Codes CoverageClassCodes
Coverage.copay.type The tytpes of services to which patient copayments are specified. Extensible Coverage Copay Type Codes CoverageCopayTypeCodes

13.1.3 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 Expression In Common
beneficiary reference Covered party Coverage.beneficiary
( Patient )
dependent string Dependent number Coverage.dependent
identifier token The primary identifier of the insured and the coverage Coverage.identifier
patient reference Retrieve coverages for a patient Coverage.beneficiary
( Patient )
payor reference The identity of the insurer or party paying for services Coverage.payor
( Organization , Patient , RelatedPerson )
policy-holder reference Reference to the policyholder Coverage.policyHolder
( Organization , Patient , RelatedPerson )
status token The status of the Coverage Coverage.status
subscriber reference Reference to the subscriber Coverage.subscriber
( Patient , RelatedPerson )
type token The kind of coverage (health plan, auto, Workers Compensation) Coverage.type