Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.

Health care programs Coverage provides a link between covered parties (patients) and insurers are significant the payors of health service costs. their healthcare costs (both insurance and self-pay).

The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.

The main (and possibly only) A unique identifier for the coverage - often referred assigned 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. this coverage.

This value may uniquely identify the coverage or it may Allows coverages to be used in conjunction with the additional identifiers below. distinguished and referenced.

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 concatenation of the Coverage.SubscriberID and the Coverage.dependant.

The status of the resource instance.

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.

The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.

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

The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer. policy.

This provides employer information in the case of Worker's Compensation and other policies.

For example: may be an individual, corporation or the subscriber's employer.

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.

This is the party who is entitled to the benfits under the policy.

May be self or a parent in the case of dependants.

The insurer assigned ID for the Subscriber.

The insurer requires this identifier on correspondance and claims (digital and otherwise).

The party who benefits from the insurance coverage., coverage; the patient when products and/or services are provided.

This is the party who receives treatment for which the costs are reimbursed under the coverage.

A unique identifier for a dependent under the coverage.

For some coverages a single identifier is issued to the Subscriber and then a unique dependent number is issued to each beneficiary.

Periodically the member number is constructed from the subscriberId and the dependant number.

The relationship of beneficiary (patient) to the subscriber.

To determine relationship between the patient and the subscriber. subscriber to determine coordination of benefits.

Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.

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.

Some insurers require the submission of the coverage term.

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).

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

May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations.

A suite of underwrite underwriter specific classifiers, classifiers.

The codes provided on the health card which identify or confirm the specific policy for the insurer.

For example may be used to identify a class of coverage or employer group, Policy, Plan.

Identifies a style or collective The type of coverage issued by the underwriter, classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify an employer group. May also be referred to as a Policy class of coverage or Group ID. employer group, Policy, Plan.

A short description The insurer issued label for the group. a specific health card value.

Identifies a style or collective of coverage issued by The alphanumeric string value associated with the underwriter, for example may be used to identify a subset of an employer group. insurer issued label.

The insurer issued label and value are necessary to identify the specific policy.

For example, the Group or Plan number.

A short description for the subgroup. class.

Used to provide a meaningful description in correspondence to the patient.

Identifies a style or collective The order of coverage issued by the underwriter, for example may be used to identify a collection applicability of benefits provided this coverage relative to employees. May other coverages which are currently in force. Note, there may be referred to gaps in the numbering and this does not imply primary, secondary etc. as a Section or Division ID. the specific positioning of coverages depends upon the episode of care.

Used in managing the coordination of benefits.

A short description The insurer-specific identifier for the plan. 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.

Used in referral for treatment and in claims processing.

Identifies a sub-style or sub-collective A suite of coverage issued by codes indicating the underwriter, for example cost category and associated amount which have been detailed in the policy and may be used to identify a subset of a collection of benefits provided to employees. have been included on the health card.

Required by providers to manage financial transaction with the patient.

For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.

A short description for the subplan. The category of patient centric costs associated with treatment.

Identifies a style or collective of coverage issues by the underwriter, for example may be used Needed to identify a class of coverage such as a level of deductables or co-payment. the category associated with the amount for the patient.

For example visit, specialist visits, emergency, inpatient care, etc.

A short description The amount due from the patient for the class. cost category.

Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used Needed to identify a subclass of coverage such as a sub-level of deductables or co-payment. the amount for the patient associated with the category.

Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.

A short description for the subclass. suite of codes indicating exceptions or reductions to patient costs and their effective periods.

Required by providers to manage financial transaction with the patient.

A unique identifier The code for a dependent under the coverage. specific exception.

For some coverage a single identifier is issued Needed to identify the Subscriber and a dependent number issued to each beneficiary. exception associated with the amount for the patient.

An optional counter for a particular instance of The timeframe during when the identified coverage which increments upon each renewal. exception is in force.

Some coverage, for example social plans, may be offered in short time increments, Needed to identify the applicable timeframe for example the exception for a week or a month at a time, so while the rest correct calculation 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'. patient costs.

The order of applicability of this coverage relative to other coverages which are currently inforce. Note, there may be gaps in the numbering and When 'subrogation=true' this does insurance instance has been included not imply primary, secondard etc. as the specific positioning of coverages depends upon for adjudication but to provide insurers with the episode of care. details to recover costs.

The insurer-specific identifier See definition for the insurer-defined network of providers when to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply. used.

Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.

The policy(s) which constitute this insurance coverage.

To reference the legally binding contract between the policy holder and the insurer.