STU 3 Candidate

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). 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

7.3 Resource Coverage - Content

Financial Management Work GroupMaturity Level: 0Compartments: Not linked to any defined compartments

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

7.3.1 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 Claim, ClaimResponse, EligibilityRequest, EnrollmentRequest and ExplanationOfBenefit

7.3.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage DomainResourceInsurance or medical plan
... issuer[x] Σ1..1Identifier for the plan issuer
.... issuerIdentifierIdentifier
.... issuerReferenceReference(Organization)
... bin 0..1stringBIN Number
... period Σ0..1PeriodCoverage start and end dates
... type Σ0..1CodingType of coverage
ActCoverageTypeCode (Example)
... planholder[x] ?!1..1Plan holder
.... planholderIdentifierIdentifier
.... planholderReferenceReference(Patient | Organization)
... beneficiary[x] ?!1..1Plan Beneficiary
.... beneficiaryIdentifierIdentifier
.... beneficiaryReferenceReference(Patient)
... relationship 1..1CodingPatient relationship to planholder
Beneficiary Relationship Codes (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..1positiveIntDependent number
... sequence Σ0..1positiveIntThe plan instance or sequence counter
... exception 0..*CodingEligibility exceptions
Exception Codes (Example)
... school 0..1stringName of School
... network Σ0..1stringInsurer network
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

UML Diagram

Coverage (DomainResource)The program or plan underwriter or payorissuer[x] : Type [1..1] « Identifier|Reference(Organization) »Business Identification Number (BIN number) used to identify the routing of eClaimsbin : string [0..1]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 forceperiod : Period [0..1]The 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.). (Strength=Example)ActCoverageTypeCode?? »The party who 'owns' the insurance contractual relationship to the policy or to whom the benefit of the policy is due (this element modifies the meaning of other elements)planholder[x] : Type [1..1] « Identifier|Reference(Patient| Organization) »The party who benefits from the insurance coverage (this element modifies the meaning of other elements)beneficiary[x] : Type [1..1] « Identifier|Reference(Patient) »The relationship of the patient to the planholdersubscriber)relationship : Coding [1..1] « The code for the relationship of the patient to the subscriber. (Strength=Example)Beneficiary Relationship ?? »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 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..1]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 IDplan : string [0..1]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 IDsubPlan : string [0..1]A unique identifier for a dependent under the coveragedependent : positiveInt [0..1]An optional counter for a particular instance of the identified coverage which increments upon each renewalsequence : positiveInt [0..1]Factors which may influence the applicability of coverageexception : Coding [0..*] « The eligibility exception codes. (Strength=Example)Exception ?? »Name of school for over-aged dependantsschool : string [0..1]The identifier for a community of providersnetwork : string [0..1]The policy(s) which constitute this insurance coveragecontract : Reference [0..*] « Contract »

XML Template

<Coverage xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <issuer[x]><!-- 1..1 Identifier|Reference(Organization) Identifier for the plan issuer --></issuer[x]>
 <bin value="[string]"/><!-- 0..1 BIN Number -->
 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <type><!-- 0..1 Coding Type of coverage --></type>
 <planholder[x]><!-- 1..1 Identifier|Reference(Patient|Organization) Plan holder --></planholder[x]>
 <beneficiary[x]><!-- 1..1 Identifier|Reference(Patient) Plan Beneficiary --></beneficiary[x]>
 <relationship><!-- 1..1 Coding Patient relationship to planholder --></relationship>
 <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="[positiveInt]"/><!-- 0..1 Dependent number -->
 <sequence value="[positiveInt]"/><!-- 0..1 The plan instance or sequence counter -->
 <exception><!-- 0..* Coding Eligibility exceptions --></exception>
 <school value="[string]"/><!-- 0..1 Name of School -->
 <network value="[string]"/><!-- 0..1 Insurer network -->
 <contract><!-- 0..* Reference(Contract) Contract details --></contract>
</Coverage>

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage DomainResourceInsurance or medical plan
... issuer[x] Σ1..1Identifier for the plan issuer
.... issuerIdentifierIdentifier
.... issuerReferenceReference(Organization)
... bin 0..1stringBIN Number
... period Σ0..1PeriodCoverage start and end dates
... type Σ0..1CodingType of coverage
ActCoverageTypeCode (Example)
... planholder[x] ?!1..1Plan holder
.... planholderIdentifierIdentifier
.... planholderReferenceReference(Patient | Organization)
... beneficiary[x] ?!1..1Plan Beneficiary
.... beneficiaryIdentifierIdentifier
.... beneficiaryReferenceReference(Patient)
... relationship 1..1CodingPatient relationship to planholder
Beneficiary Relationship Codes (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..1positiveIntDependent number
... sequence Σ0..1positiveIntThe plan instance or sequence counter
... exception 0..*CodingEligibility exceptions
Exception Codes (Example)
... school 0..1stringName of School
... network Σ0..1stringInsurer network
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

UML Diagram

Coverage (DomainResource)The program or plan underwriter or payorissuer[x] : Type [1..1] « Identifier|Reference(Organization) »Business Identification Number (BIN number) used to identify the routing of eClaimsbin : string [0..1]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 forceperiod : Period [0..1]The 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.). (Strength=Example)ActCoverageTypeCode?? »The party who 'owns' the insurance contractual relationship to the policy or to whom the benefit of the policy is due (this element modifies the meaning of other elements)planholder[x] : Type [1..1] « Identifier|Reference(Patient| Organization) »The party who benefits from the insurance coverage (this element modifies the meaning of other elements)beneficiary[x] : Type [1..1] « Identifier|Reference(Patient) »The relationship of the patient to the planholdersubscriber)relationship : Coding [1..1] « The code for the relationship of the patient to the subscriber. (Strength=Example)Beneficiary Relationship ?? »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 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..1]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 IDplan : string [0..1]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 IDsubPlan : string [0..1]A unique identifier for a dependent under the coveragedependent : positiveInt [0..1]An optional counter for a particular instance of the identified coverage which increments upon each renewalsequence : positiveInt [0..1]Factors which may influence the applicability of coverageexception : Coding [0..*] « The eligibility exception codes. (Strength=Example)Exception ?? »Name of school for over-aged dependantsschool : string [0..1]The identifier for a community of providersnetwork : string [0..1]The policy(s) which constitute this insurance coveragecontract : Reference [0..*] « Contract »

XML Template

<Coverage xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <issuer[x]><!-- 1..1 Identifier|Reference(Organization) Identifier for the plan issuer --></issuer[x]>
 <bin value="[string]"/><!-- 0..1 BIN Number -->
 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <type><!-- 0..1 Coding Type of coverage --></type>
 <planholder[x]><!-- 1..1 Identifier|Reference(Patient|Organization) Plan holder --></planholder[x]>
 <beneficiary[x]><!-- 1..1 Identifier|Reference(Patient) Plan Beneficiary --></beneficiary[x]>
 <relationship><!-- 1..1 Coding Patient relationship to planholder --></relationship>
 <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="[positiveInt]"/><!-- 0..1 Dependent number -->
 <sequence value="[positiveInt]"/><!-- 0..1 The plan instance or sequence counter -->
 <exception><!-- 0..* Coding Eligibility exceptions --></exception>
 <school value="[string]"/><!-- 0..1 Name of School -->
 <network value="[string]"/><!-- 0..1 Insurer network -->
 <contract><!-- 0..* Reference(Contract) Contract details --></contract>
</Coverage>

 

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

7.3.2.1 Terminology Bindings

PathDefinitionTypeReference
Coverage.type The type of insurance: public health, worker compensation; private accident, auto, private health, etc.).ExampleActCoverageTypeCode
Coverage.relationship The code for the relationship of the patient to the subscriber.ExampleBeneficiary Relationship Codes
Coverage.exception The eligibility exception codes.ExampleException Codes

7.3.3 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
beneficiaryidentifiertokenCovered partyCoverage.beneficiaryIdentifier
beneficiaryreferencereferenceCovered partyCoverage.beneficiaryReference
(Patient)
dependenttokenDependent numberCoverage.dependent
grouptokenGroup identifierCoverage.group
identifiertokenThe primary identifier of the insured and the coverageCoverage.identifier
issueridentifiertokenThe identity of the insurerCoverage.issuerIdentifier
issuerreferencereferenceThe identity of the insurerCoverage.issuerReference
(Organization)
plantokenA plan or policy identifierCoverage.plan
planholderidentifiertokenReference to the planholderCoverage.planholderIdentifier
planholderreferencereferenceReference to the planholderCoverage.planholderReference
(Organization, Patient)
sequencetokenSequence numberCoverage.sequence
subplantokenSub-plan identifierCoverage.subPlan
typetokenThe kind of coverage (health plan, auto, Workers Compensation)Coverage.type