This page is part of the FHIR Specification (v1.2.0: 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
Detailed Descriptions for the elements in the Coverage resource.
Coverage | |
Definition | Financial instrument which may be used to pay for or reimburse health care products and services. |
Control | 1..1 |
Requirements | Health care programs and insurers are significant payors of health service costs. |
Coverage.issuer | |
Definition | The program or plan underwriter or payor. |
Control | 0..1 |
Type | Reference(Organization) |
Requirements | Need to identify the issuer to target for processing and for coordination of benefit processing. |
Summary | true |
Coverage.bin | |
Definition | Business Identification Number (BIN number) used to identify the routing of eclaims if the insurer themselves don't have a BIN number for all of their business. |
Control | 0..1 |
Type | Identifier |
Coverage.period | |
Definition | 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. |
Control | 0..1 |
Type | Period |
Summary | true |
Coverage.type | |
Definition | The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health. |
Control | 0..1 |
Binding | ActCoverageTypeCode: The type of insurance: public health, worker compensation; private accident, auto, private health, etc.). (Example) |
Type | Coding |
Requirements | The order of application of coverages is dependent on the types of coverage. |
Summary | true |
Coverage.subscriberId | |
Definition | The id issued to the subscriber. |
Control | 0..1 |
Type | Identifier |
Summary | true |
Coverage.identifier | |
Definition | The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Subscriber Id, Certificate number or Personal Health Number or Case ID. |
Note | This is a business identifer, not a resource identifier (see discussion) |
Control | 0..* |
Type | Identifier |
Requirements | This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below. |
Summary | true |
Coverage.group | |
Definition | 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 ID. |
Control | 0..1 |
Type | string |
Summary | true |
Coverage.plan | |
Definition | 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 ID. |
Control | 0..1 |
Type | string |
Summary | true |
Coverage.subPlan | |
Definition | Identifies 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 ID. |
Control | 0..1 |
Type | string |
Summary | true |
Coverage.dependent | |
Definition | A unique identifier for a dependent under the coverage. |
Control | 0..1 |
Type | positiveInt |
Requirements | For some coverage a single identifier is issued to the PolicyHolder and dependent number issues to each to each of their dependents to track and manage the plan. |
Summary | true |
Coverage.sequence | |
Definition | An optional counter for a particular instance of the identified coverage which increments upon each renewal. |
Control | 0..1 |
Type | positiveInt |
Requirements | Some coverage, for example social plans, may be offered in short time increments, for example for a week or a month at a time, so while the rest 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'. |
Summary | true |
Coverage.subscriber | |
Definition | The party who 'owns' the insurance contractual relationship to the policy or to whom the benefit of the policy is due. |
Control | 0..1 |
Type | Reference(Patient) |
Is Modifier | true |
To Do | D01 through D09. |
Coverage.network | |
Definition | The identifier for a community of providers. |
Control | 0..1 |
Type | Identifier |
Summary | true |
Coverage.contract | |
Definition | The policy(s) which constitute this insurance coverage. |
Control | 0..* |
Type | Reference(Contract) |
To Do | D01 through D09. |