2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 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

7.2 Resource Coverage - Content

This resource maintained by the Financial Management Work Group

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

7.2.1 Scope and Usage

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

This resource is referenced by EnrollmentRequest, InstitutionalClaim, OralHealthClaim, PharmacyClaim, ProfessionalClaim, Reversal and VisionClaim

7.2.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage DomainResourceInsurance or medical plan
... issuer Σ0..1OrganizationAn identifier for the plan issuer
... period Σ0..1PeriodCoverage start and end dates
... type Σ0..1CodingType of coverage
CoverageType (Example)
... identifier Σ0..*IdentifierThe primary coverage ID
... group Σ0..1stringAn identifier for the group
... plan Σ0..1stringAn identifier for the plan
... subplan Σ0..1stringAn identifier for the subsection of the plan
... dependent Σ0..1integerThe dependent number
... sequence Σ0..1integerThe plan instance or sequence counter
... subscriber 0..1PatientPlan holder information
... network Σ0..1IdentifierInsurer network
... contract 0..*ContractContract details

UML Diagram

Coverage (DomainResource)The program or plan underwriter or payorissuer : Reference(Organization) 0..1Time 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 forceperiod : Period 0..1The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group healthtype : Coding 0..1 « (The type of insurance: public health, worker compensation; private accident, auto, private health, etc.)CoverageType) »The main (and possibly only) identifier for the coverage - often referred to as a Subscriber Id, Certificate number or Personal Health Number or Case IDidentifier : Identifier 0..*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 IDgroup : string 0..1Identifies 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 IDplan : string 0..1Identifies 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 IDsubplan : string 0..1A unique identifier for a dependent under the coveragedependent : integer 0..1An optional counter for a particular instance of the identified coverage which increments upon each renewalsequence : integer 0..1The party who 'owns' the insurance contractual relationship to the policy or to whom the benefit of the policy is duesubscriber : Reference(Patient) 0..1The identifier for a community of providersnetwork : Identifier 0..1The policy(s) which constitute this insurance coveragecontract : Reference(Contract) 0..*

XML Template

<Coverage xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <issuer><!-- 0..1 Reference(Organization) An identifier for the plan issuer --></issuer>
 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <type><!-- 0..1 Coding Type of coverage --></type>
 <identifier><!-- 0..* Identifier The primary coverage ID --></identifier>
 <group value="[string]"/><!-- 0..1 An identifier for the group -->
 <plan value="[string]"/><!-- 0..1 An identifier for the plan -->
 <subplan value="[string]"/><!-- 0..1 An identifier for the subsection of the plan -->
 <dependent value="[integer]"/><!-- 0..1 The dependent number -->
 <sequence value="[integer]"/><!-- 0..1 The plan instance or sequence counter -->
 <subscriber><!-- 0..1 Reference(Patient) Plan holder information --></subscriber>
 <network><!-- 0..1 Identifier Insurer network --></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
  "issuer" : { Reference(Organization) }, // An identifier for the plan issuer
  "period" : { Period }, // Coverage start and end dates
  "type" : { Coding }, // Type of coverage
  "identifier" : [{ Identifier }], // The primary coverage ID
  "group" : "<string>", // An identifier for the group
  "plan" : "<string>", // An identifier for the plan
  "subplan" : "<string>", // An identifier for the subsection of the plan
  "dependent" : <integer>, // The dependent number
  "sequence" : <integer>, // The plan instance or sequence counter
  "subscriber" : { Reference(Patient) }, // Plan holder information
  "network" : { Identifier }, // Insurer network
  "contract" : [{ Reference(Contract) }] // Contract details
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage DomainResourceInsurance or medical plan
... issuer Σ0..1OrganizationAn identifier for the plan issuer
... period Σ0..1PeriodCoverage start and end dates
... type Σ0..1CodingType of coverage
CoverageType (Example)
... identifier Σ0..*IdentifierThe primary coverage ID
... group Σ0..1stringAn identifier for the group
... plan Σ0..1stringAn identifier for the plan
... subplan Σ0..1stringAn identifier for the subsection of the plan
... dependent Σ0..1integerThe dependent number
... sequence Σ0..1integerThe plan instance or sequence counter
... subscriber 0..1PatientPlan holder information
... network Σ0..1IdentifierInsurer network
... contract 0..*ContractContract details

UML Diagram

Coverage (DomainResource)The program or plan underwriter or payorissuer : Reference(Organization) 0..1Time 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 forceperiod : Period 0..1The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group healthtype : Coding 0..1 « (The type of insurance: public health, worker compensation; private accident, auto, private health, etc.)CoverageType) »The main (and possibly only) identifier for the coverage - often referred to as a Subscriber Id, Certificate number or Personal Health Number or Case IDidentifier : Identifier 0..*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 IDgroup : string 0..1Identifies 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 IDplan : string 0..1Identifies 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 IDsubplan : string 0..1A unique identifier for a dependent under the coveragedependent : integer 0..1An optional counter for a particular instance of the identified coverage which increments upon each renewalsequence : integer 0..1The party who 'owns' the insurance contractual relationship to the policy or to whom the benefit of the policy is duesubscriber : Reference(Patient) 0..1The identifier for a community of providersnetwork : Identifier 0..1The policy(s) which constitute this insurance coveragecontract : Reference(Contract) 0..*

XML Template

<Coverage xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <issuer><!-- 0..1 Reference(Organization) An identifier for the plan issuer --></issuer>
 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <type><!-- 0..1 Coding Type of coverage --></type>
 <identifier><!-- 0..* Identifier The primary coverage ID --></identifier>
 <group value="[string]"/><!-- 0..1 An identifier for the group -->
 <plan value="[string]"/><!-- 0..1 An identifier for the plan -->
 <subplan value="[string]"/><!-- 0..1 An identifier for the subsection of the plan -->
 <dependent value="[integer]"/><!-- 0..1 The dependent number -->
 <sequence value="[integer]"/><!-- 0..1 The plan instance or sequence counter -->
 <subscriber><!-- 0..1 Reference(Patient) Plan holder information --></subscriber>
 <network><!-- 0..1 Identifier Insurer network --></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
  "issuer" : { Reference(Organization) }, // An identifier for the plan issuer
  "period" : { Period }, // Coverage start and end dates
  "type" : { Coding }, // Type of coverage
  "identifier" : [{ Identifier }], // The primary coverage ID
  "group" : "<string>", // An identifier for the group
  "plan" : "<string>", // An identifier for the plan
  "subplan" : "<string>", // An identifier for the subsection of the plan
  "dependent" : <integer>, // The dependent number
  "sequence" : <integer>, // The plan instance or sequence counter
  "subscriber" : { Reference(Patient) }, // Plan holder information
  "network" : { Identifier }, // Insurer network
  "contract" : [{ Reference(Contract) }] // Contract details
}

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

7.2.2.1 Terminology Bindings

PathDefinitionTypeReference
Coverage.type The type of insurance: public health, worker compensation; private accident, auto, private health, etc.)Examplehttp://hl7.org/fhir/v3/vs/ActCoverageTypeCode

7.2.3 Search Parameters

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

NameTypeDescriptionPaths
dependenttokenDependent numberCoverage.dependent
grouptokenGroup identifierCoverage.group
identifiertokenThe primary identifier of the insuredCoverage.identifier
issuerreferenceThe identity of the insurerCoverage.issuer
(Organization)
plantokenA plan or policy identifierCoverage.plan
sequencetokenSequence numberCoverage.sequence
subplantokenSub-plan identifierCoverage.subplan
typetokenThe kind of coverageCoverage.type