Resource type: coverage

Description

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

Elements

PathShortDefinitionComments
Insurance or medical plan or a payment agreementFinancial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.
identifierBusiness Identifier for the coverageA unique identifier assigned to this coverage.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.
statusactive | cancelled | draft | entered-in-errorThe status of the resource instance.This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.
typeCoverage category such as medical or accidentThe type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.
policyHolderOwner of the policyThe party who 'owns' the insurance policy.For example: may be an individual, corporation or the subscriber's employer.
subscriberSubscriber to the policyThe 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.May be self or a parent in the case of dependants.
subscriberIdID assigned to the subscriberThe insurer assigned ID for the Subscriber.
beneficiaryPlan beneficiaryThe party who benefits from the insurance coverage; the patient when products and/or services are provided.
dependentDependent numberA unique identifier for a dependent under the coverage.Periodically the member number is constructed from the subscriberId and the dependant number.
relationshipBeneficiary relationship to the subscriberThe relationship of beneficiary (patient) to the subscriber.Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.
periodCoverage start and end datesTime 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.
payorIssuer of the policyThe 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). For selfpay it may provide multiple paying persons and/or organizations.
classAdditional coverage classificationsA suite of underwriter specific classifiers.For example may be used to identify a class of coverage or employer group, Policy, Plan.
class.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
class.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
class.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
class.typeType of class such as 'group' or 'plan'The type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan.
class.valueValue associated with the typeThe alphanumeric string value associated with the insurer issued label.For example, the Group or Plan number.
class.nameHuman readable description of the type and valueA short description for the class.
orderRelative order of the coverageThe order of applicability of this coverage relative to other coverages which are currently in force. Note, there may be gaps in the numbering and this does not imply primary, secondary etc. as the specific positioning of coverages depends upon the episode of care.
networkInsurer networkThe 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.
costToBeneficiaryPatient payments for services/productsA suite of codes indicating the cost category and associated amount which have been detailed in the policy and may have been included on the health card.For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.
costToBeneficiary.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
costToBeneficiary.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
costToBeneficiary.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
costToBeneficiary.typeCost categoryThe category of patient centric costs associated with treatment.For example visit, specialist visits, emergency, inpatient care, etc.
costToBeneficiary.value[x]The amount or percentage due from the beneficiaryThe amount due from the patient for the cost category.Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.
costToBeneficiary.exceptionExceptions for patient paymentsA suite of codes indicating exceptions or reductions to patient costs and their effective periods.
costToBeneficiary.exception.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
costToBeneficiary.exception.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
costToBeneficiary.exception.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
costToBeneficiary.exception.typeException categoryThe code for the specific exception.
costToBeneficiary.exception.periodThe effective period of the exceptionThe timeframe during when the exception is in force.
subrogationReimbursement to insurerWhen 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs.Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.
contractContract detailsThe policy(s) which constitute this insurance coverage.

Scope and Usage

The Coverage resource is intended to provide the high-level identifiers and descriptors of an insurance plan, typically the information which would appear on an insurance card, which may be used to 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.

The Coverage resource is a "event" resource from a FHIR workflow perspective - see Workflow Request.

Boundaries and Relationships

The eClaim domain includes a number of related insurance resources

Coverage The Coverage resource is intended to provide the high-level identifiers and descriptors of a specific insurance plan for a specific individual - essentially the insurance card information. This may alternately provide the individual or organization, selfpay, which will pay for products and services rendered.
Contract A Contract resource holds the references to parties who have entered into an agreement of some type, the parties who may sign or witness such an agreement, descriptors of the type of agreement and even the actual text or executable copy of the agreement. The agreement may be of a variety of types including service contracts, insurance contracts, directives, etc. The contract may be either definitional or actual instances.
InsurancePlan The InsurancePlan resource holds the definition of an insurance plan which an insurer may offer to potential clients through insurance brokers or an online insurance marketplace. This is only the plan definition and does not contain or reference a list of individuals who have purchased the plan.

Search Parameters

beneficiaryCovered partyCoverage.beneficiary
class-typeCoverage class (eg. plan, group)Coverage.class.type
class-valueValue of the class (eg. Plan number, group number)Coverage.class.value
dependentDependent numberCoverage.dependent
identifierThe primary identifier of the insured and the coverageCoverage.identifier
patientRetrieve coverages for a patientCoverage.beneficiary
payorThe identity of the insurer or party paying for servicesCoverage.payor
policy-holderReference to the policyholderCoverage.policyHolder
statusThe status of the CoverageCoverage.status
subscriberReference to the subscriberCoverage.subscriber
typeThe kind of coverage (health plan, auto, Workers Compensation)Coverage.type

Extension Definitions

These are extension definitions for this resource defined by the spec