STU 3 Ballot

This page is part of the FHIR Specification (v1.6.0: STU 3 Ballot 4). 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

13.3 Resource Coverage - Content

Financial Management Work GroupMaturity Level: 1Compartments: Not linked to any defined compartments

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

13.3.1 Scope and Usage

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

This resource may also be used to register 'SelfPay' where and individual or organization other than an insurer it taking responsibility for payment for a portion of the health care costs.

This resource is referenced by Account, Claim, ClaimResponse, EligibilityRequest, EnrollmentRequest and ExplanationOfBenefit

13.3.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage DomainResourceInsurance or medical plan or a payment agreement
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
CoverageStatus (Required)
... issuer[x] Σ1..1Identifier for the plan or agreement issuer
.... issuerIdentifierIdentifier
.... issuerReferenceReference(Organization | Patient | RelatedPerson)
... isAgreement Σ0..1booleanIs a Payment Agreement
... bin Σ0..1stringBIN Number
... period Σ0..1PeriodCoverage start and end dates
... type Σ0..1CodingType of coverage
ActCoverageTypeCode (Example)
... planholder[x] Σ1..1Plan holder
.... planholderIdentifierIdentifier
.... planholderReferenceReference(Patient | Organization)
... beneficiary[x] Σ1..1Plan Beneficiary
.... beneficiaryIdentifierIdentifier
.... beneficiaryReferenceReference(Patient)
... relationship 1..1CodingBeneficiary relationship to Planholder
Policyholder Relationship Codes (Example)
... identifier Σ0..*IdentifierThe primary coverage ID
... group Σ0..1stringAn identifier for the group
... subGroup Σ0..1stringAn identifier for the subsection of the group
... plan Σ0..1stringAn identifier for the plan
... subPlan Σ0..1stringAn identifier for the subsection of the plan
... class Σ0..1stringAn identifier for the class
... dependent Σ0..1positiveIntDependent number
... sequence Σ0..1positiveIntThe plan instance or sequence counter
... network Σ0..1stringInsurer network
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

UML Diagram (Legend)

Coverage (DomainResource)The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required)CoverageStatus! »The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreementsissuer[x] : Type [1..1] « Identifier|Reference(Organization|Patient| RelatedPerson) »A self, or other, payment agreement not an insurance policyisAgreement : boolean [0..1]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 dueplanholder[x] : Type [1..1] « Identifier|Reference(Patient| Organization) »The party who benefits from the insurance coveragebeneficiary[x] : Type [1..1] « Identifier|Reference(Patient) »The relationship of beneficiary (patient) (subscriber) to the the planholderrelationship : Coding [1..1] « The relationship between the Policyholder and the Beneficiary (insured/covered party/patient). (Strength=Example)Policyholder 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 IDsubGroup : 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]Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer groupclass : 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]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 -->
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <issuer[x]><!-- 1..1 Identifier|Reference(Organization|Patient|RelatedPerson) Identifier for the plan or agreement issuer --></issuer[x]>
 <isAgreement value="[boolean]"/><!-- 0..1 Is a Payment Agreement -->
 <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 Beneficiary relationship to Planholder --></relationship>
 <identifier><!-- 0..* Identifier The primary coverage ID --></identifier>
 <group value="[string]"/><!-- 0..1 An identifier for the group -->
 <subGroup value="[string]"/><!-- 0..1 An identifier for the subsection of 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 -->
 <class value="[string]"/><!-- 0..1 An identifier for the class -->
 <dependent value="[positiveInt]"/><!-- 0..1 Dependent number -->
 <sequence value="[positiveInt]"/><!-- 0..1 The plan instance or sequence counter -->
 <network value="[string]"/><!-- 0..1 Insurer 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
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  // issuer[x]: Identifier for the plan or agreement issuer. One of these 2:
  "issuerIdentifier" : { Identifier },
  "issuerReference" : { Reference(Organization|Patient|RelatedPerson) },
  "isAgreement" : <boolean>, // Is a Payment Agreement
  "bin" : "<string>", // BIN Number
  "period" : { Period }, // Coverage start and end dates
  "type" : { Coding }, // Type of coverage
  // planholder[x]: Plan holder. One of these 2:
  "planholderIdentifier" : { Identifier },
  "planholderReference" : { Reference(Patient|Organization) },
  // beneficiary[x]: Plan Beneficiary. One of these 2:
  "beneficiaryIdentifier" : { Identifier },
  "beneficiaryReference" : { Reference(Patient) },
  "relationship" : { Coding }, // R!  Beneficiary relationship to Planholder
  "identifier" : [{ Identifier }], // The primary coverage ID
  "group" : "<string>", // An identifier for the group
  "subGroup" : "<string>", // An identifier for the subsection of the group
  "plan" : "<string>", // An identifier for the plan
  "subPlan" : "<string>", // An identifier for the subsection of the plan
  "class" : "<string>", // An identifier for the class
  "dependent" : "<positiveInt>", // Dependent number
  "sequence" : "<positiveInt>", // The plan instance or sequence counter
  "network" : "<string>", // Insurer network
  "contract" : [{ Reference(Contract) }] // Contract details
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:Coverage;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Coverage.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  # Coverage.issuer[x] : 1..1 Identifier for the plan or agreement issuer. One of these 2
    fhir:Coverage.issuerIdentifier [ Identifier ]
    fhir:Coverage.issuerReference [ Reference(Organization|Patient|RelatedPerson) ]
  fhir:Coverage.isAgreement [ boolean ]; # 0..1 Is a Payment Agreement
  fhir:Coverage.bin [ string ]; # 0..1 BIN Number
  fhir:Coverage.period [ Period ]; # 0..1 Coverage start and end dates
  fhir:Coverage.type [ Coding ]; # 0..1 Type of coverage
  # Coverage.planholder[x] : 1..1 Plan holder. One of these 2
    fhir:Coverage.planholderIdentifier [ Identifier ]
    fhir:Coverage.planholderReference [ Reference(Patient|Organization) ]
  # Coverage.beneficiary[x] : 1..1 Plan Beneficiary. One of these 2
    fhir:Coverage.beneficiaryIdentifier [ Identifier ]
    fhir:Coverage.beneficiaryReference [ Reference(Patient) ]
  fhir:Coverage.relationship [ Coding ]; # 1..1 Beneficiary relationship to Planholder
  fhir:Coverage.identifier [ Identifier ], ... ; # 0..* The primary coverage ID
  fhir:Coverage.group [ string ]; # 0..1 An identifier for the group
  fhir:Coverage.subGroup [ string ]; # 0..1 An identifier for the subsection of the group
  fhir:Coverage.plan [ string ]; # 0..1 An identifier for the plan
  fhir:Coverage.subPlan [ string ]; # 0..1 An identifier for the subsection of the plan
  fhir:Coverage.class [ string ]; # 0..1 An identifier for the class
  fhir:Coverage.dependent [ positiveInt ]; # 0..1 Dependent number
  fhir:Coverage.sequence [ positiveInt ]; # 0..1 The plan instance or sequence counter
  fhir:Coverage.network [ string ]; # 0..1 Insurer network
  fhir:Coverage.contract [ Reference(Contract) ], ... ; # 0..* Contract details
]

Changes since DSTU2

Coverage
Coverage.status added
Coverage.issuer[x] Renamed from issuer to issuer[x]
Min Cardinality changed from 0 to 1
Add Identifier, Add Reference(Patient), Add Reference(RelatedPerson)
Coverage.isAgreement added
Coverage.bin Type changed from Identifier to string
Coverage.planholder[x] added
Coverage.beneficiary[x] added
Coverage.relationship added
Coverage.subGroup added
Coverage.class added
Coverage.network Type changed from Identifier to string
Coverage.subscriberId deleted
Coverage.subscriber deleted

See the Full Difference for further information

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage DomainResourceInsurance or medical plan or a payment agreement
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
CoverageStatus (Required)
... issuer[x] Σ1..1Identifier for the plan or agreement issuer
.... issuerIdentifierIdentifier
.... issuerReferenceReference(Organization | Patient | RelatedPerson)
... isAgreement Σ0..1booleanIs a Payment Agreement
... bin Σ0..1stringBIN Number
... period Σ0..1PeriodCoverage start and end dates
... type Σ0..1CodingType of coverage
ActCoverageTypeCode (Example)
... planholder[x] Σ1..1Plan holder
.... planholderIdentifierIdentifier
.... planholderReferenceReference(Patient | Organization)
... beneficiary[x] Σ1..1Plan Beneficiary
.... beneficiaryIdentifierIdentifier
.... beneficiaryReferenceReference(Patient)
... relationship 1..1CodingBeneficiary relationship to Planholder
Policyholder Relationship Codes (Example)
... identifier Σ0..*IdentifierThe primary coverage ID
... group Σ0..1stringAn identifier for the group
... subGroup Σ0..1stringAn identifier for the subsection of the group
... plan Σ0..1stringAn identifier for the plan
... subPlan Σ0..1stringAn identifier for the subsection of the plan
... class Σ0..1stringAn identifier for the class
... dependent Σ0..1positiveIntDependent number
... sequence Σ0..1positiveIntThe plan instance or sequence counter
... network Σ0..1stringInsurer network
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

UML Diagram (Legend)

Coverage (DomainResource)The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required)CoverageStatus! »The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreementsissuer[x] : Type [1..1] « Identifier|Reference(Organization|Patient| RelatedPerson) »A self, or other, payment agreement not an insurance policyisAgreement : boolean [0..1]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 dueplanholder[x] : Type [1..1] « Identifier|Reference(Patient| Organization) »The party who benefits from the insurance coveragebeneficiary[x] : Type [1..1] « Identifier|Reference(Patient) »The relationship of beneficiary (patient) (subscriber) to the the planholderrelationship : Coding [1..1] « The relationship between the Policyholder and the Beneficiary (insured/covered party/patient). (Strength=Example)Policyholder 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 IDsubGroup : 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]Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage or employer groupclass : 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]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 -->
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <issuer[x]><!-- 1..1 Identifier|Reference(Organization|Patient|RelatedPerson) Identifier for the plan or agreement issuer --></issuer[x]>
 <isAgreement value="[boolean]"/><!-- 0..1 Is a Payment Agreement -->
 <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 Beneficiary relationship to Planholder --></relationship>
 <identifier><!-- 0..* Identifier The primary coverage ID --></identifier>
 <group value="[string]"/><!-- 0..1 An identifier for the group -->
 <subGroup value="[string]"/><!-- 0..1 An identifier for the subsection of 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 -->
 <class value="[string]"/><!-- 0..1 An identifier for the class -->
 <dependent value="[positiveInt]"/><!-- 0..1 Dependent number -->
 <sequence value="[positiveInt]"/><!-- 0..1 The plan instance or sequence counter -->
 <network value="[string]"/><!-- 0..1 Insurer 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
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  // issuer[x]: Identifier for the plan or agreement issuer. One of these 2:
  "issuerIdentifier" : { Identifier },
  "issuerReference" : { Reference(Organization|Patient|RelatedPerson) },
  "isAgreement" : <boolean>, // Is a Payment Agreement
  "bin" : "<string>", // BIN Number
  "period" : { Period }, // Coverage start and end dates
  "type" : { Coding }, // Type of coverage
  // planholder[x]: Plan holder. One of these 2:
  "planholderIdentifier" : { Identifier },
  "planholderReference" : { Reference(Patient|Organization) },
  // beneficiary[x]: Plan Beneficiary. One of these 2:
  "beneficiaryIdentifier" : { Identifier },
  "beneficiaryReference" : { Reference(Patient) },
  "relationship" : { Coding }, // R!  Beneficiary relationship to Planholder
  "identifier" : [{ Identifier }], // The primary coverage ID
  "group" : "<string>", // An identifier for the group
  "subGroup" : "<string>", // An identifier for the subsection of the group
  "plan" : "<string>", // An identifier for the plan
  "subPlan" : "<string>", // An identifier for the subsection of the plan
  "class" : "<string>", // An identifier for the class
  "dependent" : "<positiveInt>", // Dependent number
  "sequence" : "<positiveInt>", // The plan instance or sequence counter
  "network" : "<string>", // Insurer network
  "contract" : [{ Reference(Contract) }] // Contract details
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:Coverage;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Coverage.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  # Coverage.issuer[x] : 1..1 Identifier for the plan or agreement issuer. One of these 2
    fhir:Coverage.issuerIdentifier [ Identifier ]
    fhir:Coverage.issuerReference [ Reference(Organization|Patient|RelatedPerson) ]
  fhir:Coverage.isAgreement [ boolean ]; # 0..1 Is a Payment Agreement
  fhir:Coverage.bin [ string ]; # 0..1 BIN Number
  fhir:Coverage.period [ Period ]; # 0..1 Coverage start and end dates
  fhir:Coverage.type [ Coding ]; # 0..1 Type of coverage
  # Coverage.planholder[x] : 1..1 Plan holder. One of these 2
    fhir:Coverage.planholderIdentifier [ Identifier ]
    fhir:Coverage.planholderReference [ Reference(Patient|Organization) ]
  # Coverage.beneficiary[x] : 1..1 Plan Beneficiary. One of these 2
    fhir:Coverage.beneficiaryIdentifier [ Identifier ]
    fhir:Coverage.beneficiaryReference [ Reference(Patient) ]
  fhir:Coverage.relationship [ Coding ]; # 1..1 Beneficiary relationship to Planholder
  fhir:Coverage.identifier [ Identifier ], ... ; # 0..* The primary coverage ID
  fhir:Coverage.group [ string ]; # 0..1 An identifier for the group
  fhir:Coverage.subGroup [ string ]; # 0..1 An identifier for the subsection of the group
  fhir:Coverage.plan [ string ]; # 0..1 An identifier for the plan
  fhir:Coverage.subPlan [ string ]; # 0..1 An identifier for the subsection of the plan
  fhir:Coverage.class [ string ]; # 0..1 An identifier for the class
  fhir:Coverage.dependent [ positiveInt ]; # 0..1 Dependent number
  fhir:Coverage.sequence [ positiveInt ]; # 0..1 The plan instance or sequence counter
  fhir:Coverage.network [ string ]; # 0..1 Insurer network
  fhir:Coverage.contract [ Reference(Contract) ], ... ; # 0..* Contract details
]

Changes since DSTU2

Coverage
Coverage.status added
Coverage.issuer[x] Renamed from issuer to issuer[x]
Min Cardinality changed from 0 to 1
Add Identifier, Add Reference(Patient), Add Reference(RelatedPerson)
Coverage.isAgreement added
Coverage.bin Type changed from Identifier to string
Coverage.planholder[x] added
Coverage.beneficiary[x] added
Coverage.relationship added
Coverage.subGroup added
Coverage.class added
Coverage.network Type changed from Identifier to string
Coverage.subscriberId deleted
Coverage.subscriber deleted

See the Full Difference for further information

 

Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron (for ) + JSON Schema, ShEx (for Turtle)

13.3.2.1 Terminology Bindings

PathDefinitionTypeReference
Coverage.status A code specifying the state of the resource instance.RequiredCoverageStatus
Coverage.type The type of insurance: public health, worker compensation; private accident, auto, private health, etc.).ExampleActCoverageTypeCode
Coverage.relationship The relationship between the Policyholder and the Beneficiary (insured/covered party/patient).ExamplePolicyholder Relationship Codes

13.3.3 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
beneficiary-identifiertokenCovered partyCoverage.beneficiaryIdentifier
beneficiary-referencereferenceCovered partyCoverage.beneficiaryReference
(Patient)
dependentnumberDependent numberCoverage.dependent
grouptokenGroup identifierCoverage.group
identifiertokenThe primary identifier of the insured and the coverageCoverage.identifier
issuer-identifiertokenThe identity of the insurerCoverage.issuerIdentifier
issuer-referencereferenceThe identity of the insurerCoverage.issuerReference
(Organization, Patient, RelatedPerson)
plantokenA plan or policy identifierCoverage.plan
planholder-identifiertokenReference to the planholderCoverage.planholderIdentifier
planholder-referencereferenceReference to the planholderCoverage.planholderReference
(Organization, Patient)
sequencenumberSequence numberCoverage.sequence
subgrouptokenSub-group identifierCoverage.subGroup
subplantokenSub-plan identifierCoverage.subPlan
typetokenThe kind of coverage (health plan, auto, Workers Compensation)Coverage.type