R4 Draft for Comment

This page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). 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

13.1 Resource Coverage - Content

Financial Management Work GroupMaturity Level: 2 Trial Use Compartments: Patient, RelatedPerson

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

13.1.1 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 an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs.

Notes to Reviewers: The following subclasses have been added to the resource for review:

  • class - this is a list of elements to replace the grouping element and sequence element; and
  • copay - this is a list of co-payment information provided on the insurance card or otherwise gathered from the insurer

This resource is referenced by Account, Claim, ClaimResponse, DeviceRequest, EligibilityRequest, EligibilityResponse, EnrollmentRequest, ExplanationOfBenefit, MedicationRequest and ServiceRequest

13.1.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage TUDomainResourceInsurance or medical plan or a payment agreement
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ0..*IdentifierThe primary coverage ID
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... type Σ0..1CodeableConceptType of coverage such as medical or accident
Coverage Type and Self-Pay Codes (Preferred)
... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId Σ0..1stringID assigned to the Subscriber
... beneficiary Σ0..1Reference(Patient)Plan Beneficiary
... dependent Σ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the Subscriber
Policyholder Relationship Codes (Example)
... period Σ0..1PeriodCoverage start and end dates
... payor Σ0..*Reference(Organization | Patient | RelatedPerson)Identifier for the plan or agreement issuer
... class 0..*BackboneElementAdditional coverage classifications
.... type Σ1..1CodingType of class such as 'group' or 'plan'
Coverage Level Codes (Extensible)
.... value Σ1..1stringThe tag or value under the classification
.... name Σ0..1stringDisplay text for an identifier for the group
... grouping 0..1BackboneElementAdditional coverage classifications
.... group Σ0..1stringAn identifier for the group
.... groupDisplay Σ0..1stringDisplay text for an identifier for the group
.... subGroup Σ0..1stringAn identifier for the subsection of the group
.... subGroupDisplay Σ0..1stringDisplay text for the subsection of the group
.... plan Σ0..1stringAn identifier for the plan
.... planDisplay Σ0..1stringDisplay text for the plan
.... subPlan Σ0..1stringAn identifier for the subsection of the plan
.... subPlanDisplay Σ0..1stringDisplay text for the subsection of the plan
.... class Σ0..1stringAn identifier for the class
.... classDisplay Σ0..1stringDisplay text for the class
.... subClass Σ0..1stringAn identifier for the subsection of the class
.... subClassDisplay Σ0..1stringDisplay text for the subsection of the subclass
... sequence Σ0..1stringThe plan instance or sequence counter
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... copay 0..*BackboneElementPatient payments for services/products
.... type Σ0..1CodingThe type of service or product
Coverage Copay Type Codes (Extensible)
.... value Σ1..1QuantityThe amount or percentage of the copayment
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

UML Diagram (Legend)

Coverage (DomainResource)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 concatination of the Coverage.SubscriberID and the Coverage.dependantidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! »The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organizationtype : CodeableConcept [0..1] « The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. (Strength=Preferred)Coverage Type and Self-Pay ? »The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employerpolicyHolder : Reference [0..1] « Patient|RelatedPerson|Organization »The 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 duesubscriber : Reference [0..1] « Patient|RelatedPerson »The insurer assigned ID for the SubscribersubscriberId : string [0..1]The party who benefits from the insurance coverage., the patient when services are providedbeneficiary : Reference [0..1] « Patient »A unique identifier for a dependent under the coveragedependent : string [0..1]The relationship of beneficiary (patient) to the subscriberrelationship : CodeableConcept [0..1] « The relationship between the Policyholder and the Beneficiary (insured/covered party/patient). (Strength=Example)Policyholder Relationship ?? »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 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)payor : Reference [0..*] « Organization|Patient|RelatedPerson »An optional counter for a particular instance of the identified coverage which increments upon each renewalsequence : string [0..1]The order of applicability of this coverage relative to other coverages which are currently inforce. Note, there may be gaps in the numbering and this does not imply primary, secondard etc. as the specific positioning of coverages depends upon the episode of careorder : positiveInt [0..1]The 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 applynetwork : string [0..1]The policy(s) which constitute this insurance coveragecontract : Reference [0..*] « Contract »ClassThe type of classification for which an insurer-specific class tag or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plantype : Coding [1..1] « The policy classifications, eg. Group, Plan, Class, etc. (Strength=Extensible)Coverage Level + »For example the Group or Plan numbervalue : string [1..1]A short description for the classname : string [0..1]GroupIdentifies a style or collective of coverage issued by the underwriter, for example may be used to identify an employer group. May also be referred to as a Policy or Group IDgroup : string [0..1]A short description for the groupgroupDisplay : string [0..1]Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a subset of an employer groupsubGroup : string [0..1]A short description for the subgroupsubGroupDisplay : string [0..1]Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a collection of benefits provided to employees. May be referred to as a Section or Division IDplan : string [0..1]A short description for the planplanDisplay : string [0..1]Identifies a sub-style or sub-collective of coverage issued by the underwriter, for example may be used to identify a subset of a collection of benefits provided to employeessubPlan : string [0..1]A short description for the subplansubPlanDisplay : 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 such as a level of deductables or co-paymentclass : string [0..1]A short description for the classclassDisplay : string [0..1]Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a subclass of coverage such as a sub-level of deductables or co-paymentsubClass : string [0..1]A short description for the subclasssubClassDisplay : string [0..1]CoPayTypes of products or services such as visit, specialist vists, emergency, inpatient care, etctype : Coding [0..1] « The tytpes of services to which patient copayments are specified. (Strength=Extensible)Coverage Copay Type + »The amount of patient payments for various types of services/products, expressed as a percentage of the service/product cost or a fixed amount of currency,value : Quantity [1..1]A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Planclass[0..*]A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plangrouping[0..1]A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plancopay[0..*]

XML Template

<Coverage xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier The primary coverage ID --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Type of coverage such as medical or accident --></type>
 <policyHolder><!-- 0..1 Reference(Patient|RelatedPerson|Organization) Owner of the policy --></policyHolder>
 <subscriber><!-- 0..1 Reference(Patient|RelatedPerson) Subscriber to the policy --></subscriber>
 <subscriberId value="[string]"/><!-- 0..1 ID assigned to the Subscriber -->
 <beneficiary><!-- 0..1 Reference(Patient) Plan Beneficiary --></beneficiary>
 <dependent value="[string]"/><!-- 0..1 Dependent number -->
 <relationship><!-- 0..1 CodeableConcept Beneficiary relationship to the Subscriber --></relationship>
 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <payor><!-- 0..* Reference(Organization|Patient|RelatedPerson) Identifier for the plan or agreement issuer --></payor>
 <class>  <!-- 0..* Additional coverage classifications -->
  <type><!-- 1..1 Coding Type of class such as 'group' or 'plan' --></type>
  <value value="[string]"/><!-- 1..1 The tag or value under the classification -->
  <name value="[string]"/><!-- 0..1 Display text for an identifier for the group -->
 </class>
 <grouping>  <!-- 0..1 Additional coverage classifications -->
  <group value="[string]"/><!-- 0..1 An identifier for the group -->
  <groupDisplay value="[string]"/><!-- 0..1 Display text for an identifier for the group -->
  <subGroup value="[string]"/><!-- 0..1 An identifier for the subsection of the group -->
  <subGroupDisplay value="[string]"/><!-- 0..1 Display text for the subsection of the group -->
  <plan value="[string]"/><!-- 0..1 An identifier for the plan -->
  <planDisplay value="[string]"/><!-- 0..1 Display text for the plan -->
  <subPlan value="[string]"/><!-- 0..1 An identifier for the subsection of the plan -->
  <subPlanDisplay value="[string]"/><!-- 0..1 Display text for the subsection of the plan -->
  <class value="[string]"/><!-- 0..1 An identifier for the class -->
  <classDisplay value="[string]"/><!-- 0..1 Display text for the class -->
  <subClass value="[string]"/><!-- 0..1 An identifier for the subsection of the class -->
  <subClassDisplay value="[string]"/><!-- 0..1 Display text for the subsection of the subclass -->
 </grouping>
 <sequence value="[string]"/><!-- 0..1 The plan instance or sequence counter -->
 <order value="[positiveInt]"/><!-- 0..1 Relative order of the coverage -->
 <network value="[string]"/><!-- 0..1 Insurer network -->
 <copay>  <!-- 0..* Patient payments for services/products -->
  <type><!-- 0..1 Coding The type of service or product --></type>
  <value><!-- 1..1 Quantity The amount or percentage of the copayment --></value>
 </copay>
 <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
  "identifier" : [{ Identifier }], // The primary coverage ID
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Type of coverage such as medical or accident
  "policyHolder" : { Reference(Patient|RelatedPerson|Organization) }, // Owner of the policy
  "subscriber" : { Reference(Patient|RelatedPerson) }, // Subscriber to the policy
  "subscriberId" : "<string>", // ID assigned to the Subscriber
  "beneficiary" : { Reference(Patient) }, // Plan Beneficiary
  "dependent" : "<string>", // Dependent number
  "relationship" : { CodeableConcept }, // Beneficiary relationship to the Subscriber
  "period" : { Period }, // Coverage start and end dates
  "payor" : [{ Reference(Organization|Patient|RelatedPerson) }], // Identifier for the plan or agreement issuer
  "class" : [{ // Additional coverage classifications
    "type" : { Coding }, // R!  Type of class such as 'group' or 'plan'
    "value" : "<string>", // R!  The tag or value under the classification
    "name" : "<string>" // Display text for an identifier for the group
  }],
  "grouping" : { // Additional coverage classifications
    "group" : "<string>", // An identifier for the group
    "groupDisplay" : "<string>", // Display text for an identifier for the group
    "subGroup" : "<string>", // An identifier for the subsection of the group
    "subGroupDisplay" : "<string>", // Display text for the subsection of the group
    "plan" : "<string>", // An identifier for the plan
    "planDisplay" : "<string>", // Display text for the plan
    "subPlan" : "<string>", // An identifier for the subsection of the plan
    "subPlanDisplay" : "<string>", // Display text for the subsection of the plan
    "class" : "<string>", // An identifier for the class
    "classDisplay" : "<string>", // Display text for the class
    "subClass" : "<string>", // An identifier for the subsection of the class
    "subClassDisplay" : "<string>" // Display text for the subsection of the subclass
  },
  "sequence" : "<string>", // The plan instance or sequence counter
  "order" : "<positiveInt>", // Relative order of the coverage
  "network" : "<string>", // Insurer network
  "copay" : [{ // Patient payments for services/products
    "type" : { Coding }, // The type of service or product
    "value" : { Quantity } // R!  The amount or percentage of the copayment
  }],
  "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.identifier [ Identifier ], ... ; # 0..* The primary coverage ID
  fhir:Coverage.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:Coverage.type [ CodeableConcept ]; # 0..1 Type of coverage such as medical or accident
  fhir:Coverage.policyHolder [ Reference(Patient|RelatedPerson|Organization) ]; # 0..1 Owner of the policy
  fhir:Coverage.subscriber [ Reference(Patient|RelatedPerson) ]; # 0..1 Subscriber to the policy
  fhir:Coverage.subscriberId [ string ]; # 0..1 ID assigned to the Subscriber
  fhir:Coverage.beneficiary [ Reference(Patient) ]; # 0..1 Plan Beneficiary
  fhir:Coverage.dependent [ string ]; # 0..1 Dependent number
  fhir:Coverage.relationship [ CodeableConcept ]; # 0..1 Beneficiary relationship to the Subscriber
  fhir:Coverage.period [ Period ]; # 0..1 Coverage start and end dates
  fhir:Coverage.payor [ Reference(Organization|Patient|RelatedPerson) ], ... ; # 0..* Identifier for the plan or agreement issuer
  fhir:Coverage.class [ # 0..* Additional coverage classifications
    fhir:Coverage.class.type [ Coding ]; # 1..1 Type of class such as 'group' or 'plan'
    fhir:Coverage.class.value [ string ]; # 1..1 The tag or value under the classification
    fhir:Coverage.class.name [ string ]; # 0..1 Display text for an identifier for the group
  ], ...;
  fhir:Coverage.grouping [ # 0..1 Additional coverage classifications
    fhir:Coverage.grouping.group [ string ]; # 0..1 An identifier for the group
    fhir:Coverage.grouping.groupDisplay [ string ]; # 0..1 Display text for an identifier for the group
    fhir:Coverage.grouping.subGroup [ string ]; # 0..1 An identifier for the subsection of the group
    fhir:Coverage.grouping.subGroupDisplay [ string ]; # 0..1 Display text for the subsection of the group
    fhir:Coverage.grouping.plan [ string ]; # 0..1 An identifier for the plan
    fhir:Coverage.grouping.planDisplay [ string ]; # 0..1 Display text for the plan
    fhir:Coverage.grouping.subPlan [ string ]; # 0..1 An identifier for the subsection of the plan
    fhir:Coverage.grouping.subPlanDisplay [ string ]; # 0..1 Display text for the subsection of the plan
    fhir:Coverage.grouping.class [ string ]; # 0..1 An identifier for the class
    fhir:Coverage.grouping.classDisplay [ string ]; # 0..1 Display text for the class
    fhir:Coverage.grouping.subClass [ string ]; # 0..1 An identifier for the subsection of the class
    fhir:Coverage.grouping.subClassDisplay [ string ]; # 0..1 Display text for the subsection of the subclass
  ];
  fhir:Coverage.sequence [ string ]; # 0..1 The plan instance or sequence counter
  fhir:Coverage.order [ positiveInt ]; # 0..1 Relative order of the coverage
  fhir:Coverage.network [ string ]; # 0..1 Insurer network
  fhir:Coverage.copay [ # 0..* Patient payments for services/products
    fhir:Coverage.copay.type [ Coding ]; # 0..1 The type of service or product
    fhir:Coverage.copay.value [ Quantity ]; # 1..1 The amount or percentage of the copayment
  ], ...;
  fhir:Coverage.contract [ Reference(Contract) ], ... ; # 0..* Contract details
]

Changes since DSTU2

Coverage
Coverage.status
  • Added Element
Coverage.type
  • Type changed from Coding to CodeableConcept
Coverage.policyHolder
  • Added Element
Coverage.subscriber
  • Add Reference(RelatedPerson)
  • No longer marked as Modifier
Coverage.subscriberId
  • Type changed from Identifier to string
Coverage.beneficiary
  • Added Element
Coverage.dependent
  • Type changed from positiveInt to string
Coverage.relationship
  • Added Element
Coverage.payor
  • Added Element
Coverage.class
  • Added Element
Coverage.class.type
  • Added Element
Coverage.class.value
  • Added Element
Coverage.class.name
  • Added Element
Coverage.grouping
  • Added Element
Coverage.grouping.group
  • Added Element
Coverage.grouping.groupDisplay
  • Added Element
Coverage.grouping.subGroup
  • Added Element
Coverage.grouping.subGroupDisplay
  • Added Element
Coverage.grouping.plan
  • Added Element
Coverage.grouping.planDisplay
  • Added Element
Coverage.grouping.subPlan
  • Added Element
Coverage.grouping.subPlanDisplay
  • Added Element
Coverage.grouping.class
  • Added Element
Coverage.grouping.classDisplay
  • Added Element
Coverage.grouping.subClass
  • Added Element
Coverage.grouping.subClassDisplay
  • Added Element
Coverage.sequence
  • Type changed from positiveInt to string
Coverage.order
  • Added Element
Coverage.network
  • Type changed from Identifier to string
Coverage.copay
  • Added Element
Coverage.copay.type
  • Added Element
Coverage.copay.value
  • Added Element
Coverage.issuer
  • deleted
Coverage.bin
  • deleted
Coverage.group
  • deleted
Coverage.plan
  • deleted
Coverage.subPlan
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage TUDomainResourceInsurance or medical plan or a payment agreement
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ0..*IdentifierThe primary coverage ID
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... type Σ0..1CodeableConceptType of coverage such as medical or accident
Coverage Type and Self-Pay Codes (Preferred)
... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId Σ0..1stringID assigned to the Subscriber
... beneficiary Σ0..1Reference(Patient)Plan Beneficiary
... dependent Σ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the Subscriber
Policyholder Relationship Codes (Example)
... period Σ0..1PeriodCoverage start and end dates
... payor Σ0..*Reference(Organization | Patient | RelatedPerson)Identifier for the plan or agreement issuer
... class 0..*BackboneElementAdditional coverage classifications
.... type Σ1..1CodingType of class such as 'group' or 'plan'
Coverage Level Codes (Extensible)
.... value Σ1..1stringThe tag or value under the classification
.... name Σ0..1stringDisplay text for an identifier for the group
... grouping 0..1BackboneElementAdditional coverage classifications
.... group Σ0..1stringAn identifier for the group
.... groupDisplay Σ0..1stringDisplay text for an identifier for the group
.... subGroup Σ0..1stringAn identifier for the subsection of the group
.... subGroupDisplay Σ0..1stringDisplay text for the subsection of the group
.... plan Σ0..1stringAn identifier for the plan
.... planDisplay Σ0..1stringDisplay text for the plan
.... subPlan Σ0..1stringAn identifier for the subsection of the plan
.... subPlanDisplay Σ0..1stringDisplay text for the subsection of the plan
.... class Σ0..1stringAn identifier for the class
.... classDisplay Σ0..1stringDisplay text for the class
.... subClass Σ0..1stringAn identifier for the subsection of the class
.... subClassDisplay Σ0..1stringDisplay text for the subsection of the subclass
... sequence Σ0..1stringThe plan instance or sequence counter
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... copay 0..*BackboneElementPatient payments for services/products
.... type Σ0..1CodingThe type of service or product
Coverage Copay Type Codes (Extensible)
.... value Σ1..1QuantityThe amount or percentage of the copayment
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

UML Diagram (Legend)

Coverage (DomainResource)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 concatination of the Coverage.SubscriberID and the Coverage.dependantidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! »The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organizationtype : CodeableConcept [0..1] « The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. (Strength=Preferred)Coverage Type and Self-Pay ? »The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employerpolicyHolder : Reference [0..1] « Patient|RelatedPerson|Organization »The 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 duesubscriber : Reference [0..1] « Patient|RelatedPerson »The insurer assigned ID for the SubscribersubscriberId : string [0..1]The party who benefits from the insurance coverage., the patient when services are providedbeneficiary : Reference [0..1] « Patient »A unique identifier for a dependent under the coveragedependent : string [0..1]The relationship of beneficiary (patient) to the subscriberrelationship : CodeableConcept [0..1] « The relationship between the Policyholder and the Beneficiary (insured/covered party/patient). (Strength=Example)Policyholder Relationship ?? »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 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)payor : Reference [0..*] « Organization|Patient|RelatedPerson »An optional counter for a particular instance of the identified coverage which increments upon each renewalsequence : string [0..1]The order of applicability of this coverage relative to other coverages which are currently inforce. Note, there may be gaps in the numbering and this does not imply primary, secondard etc. as the specific positioning of coverages depends upon the episode of careorder : positiveInt [0..1]The 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 applynetwork : string [0..1]The policy(s) which constitute this insurance coveragecontract : Reference [0..*] « Contract »ClassThe type of classification for which an insurer-specific class tag or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plantype : Coding [1..1] « The policy classifications, eg. Group, Plan, Class, etc. (Strength=Extensible)Coverage Level + »For example the Group or Plan numbervalue : string [1..1]A short description for the classname : string [0..1]GroupIdentifies a style or collective of coverage issued by the underwriter, for example may be used to identify an employer group. May also be referred to as a Policy or Group IDgroup : string [0..1]A short description for the groupgroupDisplay : string [0..1]Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a subset of an employer groupsubGroup : string [0..1]A short description for the subgroupsubGroupDisplay : string [0..1]Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a collection of benefits provided to employees. May be referred to as a Section or Division IDplan : string [0..1]A short description for the planplanDisplay : string [0..1]Identifies a sub-style or sub-collective of coverage issued by the underwriter, for example may be used to identify a subset of a collection of benefits provided to employeessubPlan : string [0..1]A short description for the subplansubPlanDisplay : 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 such as a level of deductables or co-paymentclass : string [0..1]A short description for the classclassDisplay : string [0..1]Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a subclass of coverage such as a sub-level of deductables or co-paymentsubClass : string [0..1]A short description for the subclasssubClassDisplay : string [0..1]CoPayTypes of products or services such as visit, specialist vists, emergency, inpatient care, etctype : Coding [0..1] « The tytpes of services to which patient copayments are specified. (Strength=Extensible)Coverage Copay Type + »The amount of patient payments for various types of services/products, expressed as a percentage of the service/product cost or a fixed amount of currency,value : Quantity [1..1]A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Planclass[0..*]A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plangrouping[0..1]A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plancopay[0..*]

XML Template

<Coverage xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier The primary coverage ID --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Type of coverage such as medical or accident --></type>
 <policyHolder><!-- 0..1 Reference(Patient|RelatedPerson|Organization) Owner of the policy --></policyHolder>
 <subscriber><!-- 0..1 Reference(Patient|RelatedPerson) Subscriber to the policy --></subscriber>
 <subscriberId value="[string]"/><!-- 0..1 ID assigned to the Subscriber -->
 <beneficiary><!-- 0..1 Reference(Patient) Plan Beneficiary --></beneficiary>
 <dependent value="[string]"/><!-- 0..1 Dependent number -->
 <relationship><!-- 0..1 CodeableConcept Beneficiary relationship to the Subscriber --></relationship>
 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <payor><!-- 0..* Reference(Organization|Patient|RelatedPerson) Identifier for the plan or agreement issuer --></payor>
 <class>  <!-- 0..* Additional coverage classifications -->
  <type><!-- 1..1 Coding Type of class such as 'group' or 'plan' --></type>
  <value value="[string]"/><!-- 1..1 The tag or value under the classification -->
  <name value="[string]"/><!-- 0..1 Display text for an identifier for the group -->
 </class>
 <grouping>  <!-- 0..1 Additional coverage classifications -->
  <group value="[string]"/><!-- 0..1 An identifier for the group -->
  <groupDisplay value="[string]"/><!-- 0..1 Display text for an identifier for the group -->
  <subGroup value="[string]"/><!-- 0..1 An identifier for the subsection of the group -->
  <subGroupDisplay value="[string]"/><!-- 0..1 Display text for the subsection of the group -->
  <plan value="[string]"/><!-- 0..1 An identifier for the plan -->
  <planDisplay value="[string]"/><!-- 0..1 Display text for the plan -->
  <subPlan value="[string]"/><!-- 0..1 An identifier for the subsection of the plan -->
  <subPlanDisplay value="[string]"/><!-- 0..1 Display text for the subsection of the plan -->
  <class value="[string]"/><!-- 0..1 An identifier for the class -->
  <classDisplay value="[string]"/><!-- 0..1 Display text for the class -->
  <subClass value="[string]"/><!-- 0..1 An identifier for the subsection of the class -->
  <subClassDisplay value="[string]"/><!-- 0..1 Display text for the subsection of the subclass -->
 </grouping>
 <sequence value="[string]"/><!-- 0..1 The plan instance or sequence counter -->
 <order value="[positiveInt]"/><!-- 0..1 Relative order of the coverage -->
 <network value="[string]"/><!-- 0..1 Insurer network -->
 <copay>  <!-- 0..* Patient payments for services/products -->
  <type><!-- 0..1 Coding The type of service or product --></type>
  <value><!-- 1..1 Quantity The amount or percentage of the copayment --></value>
 </copay>
 <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
  "identifier" : [{ Identifier }], // The primary coverage ID
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Type of coverage such as medical or accident
  "policyHolder" : { Reference(Patient|RelatedPerson|Organization) }, // Owner of the policy
  "subscriber" : { Reference(Patient|RelatedPerson) }, // Subscriber to the policy
  "subscriberId" : "<string>", // ID assigned to the Subscriber
  "beneficiary" : { Reference(Patient) }, // Plan Beneficiary
  "dependent" : "<string>", // Dependent number
  "relationship" : { CodeableConcept }, // Beneficiary relationship to the Subscriber
  "period" : { Period }, // Coverage start and end dates
  "payor" : [{ Reference(Organization|Patient|RelatedPerson) }], // Identifier for the plan or agreement issuer
  "class" : [{ // Additional coverage classifications
    "type" : { Coding }, // R!  Type of class such as 'group' or 'plan'
    "value" : "<string>", // R!  The tag or value under the classification
    "name" : "<string>" // Display text for an identifier for the group
  }],
  "grouping" : { // Additional coverage classifications
    "group" : "<string>", // An identifier for the group
    "groupDisplay" : "<string>", // Display text for an identifier for the group
    "subGroup" : "<string>", // An identifier for the subsection of the group
    "subGroupDisplay" : "<string>", // Display text for the subsection of the group
    "plan" : "<string>", // An identifier for the plan
    "planDisplay" : "<string>", // Display text for the plan
    "subPlan" : "<string>", // An identifier for the subsection of the plan
    "subPlanDisplay" : "<string>", // Display text for the subsection of the plan
    "class" : "<string>", // An identifier for the class
    "classDisplay" : "<string>", // Display text for the class
    "subClass" : "<string>", // An identifier for the subsection of the class
    "subClassDisplay" : "<string>" // Display text for the subsection of the subclass
  },
  "sequence" : "<string>", // The plan instance or sequence counter
  "order" : "<positiveInt>", // Relative order of the coverage
  "network" : "<string>", // Insurer network
  "copay" : [{ // Patient payments for services/products
    "type" : { Coding }, // The type of service or product
    "value" : { Quantity } // R!  The amount or percentage of the copayment
  }],
  "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.identifier [ Identifier ], ... ; # 0..* The primary coverage ID
  fhir:Coverage.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:Coverage.type [ CodeableConcept ]; # 0..1 Type of coverage such as medical or accident
  fhir:Coverage.policyHolder [ Reference(Patient|RelatedPerson|Organization) ]; # 0..1 Owner of the policy
  fhir:Coverage.subscriber [ Reference(Patient|RelatedPerson) ]; # 0..1 Subscriber to the policy
  fhir:Coverage.subscriberId [ string ]; # 0..1 ID assigned to the Subscriber
  fhir:Coverage.beneficiary [ Reference(Patient) ]; # 0..1 Plan Beneficiary
  fhir:Coverage.dependent [ string ]; # 0..1 Dependent number
  fhir:Coverage.relationship [ CodeableConcept ]; # 0..1 Beneficiary relationship to the Subscriber
  fhir:Coverage.period [ Period ]; # 0..1 Coverage start and end dates
  fhir:Coverage.payor [ Reference(Organization|Patient|RelatedPerson) ], ... ; # 0..* Identifier for the plan or agreement issuer
  fhir:Coverage.class [ # 0..* Additional coverage classifications
    fhir:Coverage.class.type [ Coding ]; # 1..1 Type of class such as 'group' or 'plan'
    fhir:Coverage.class.value [ string ]; # 1..1 The tag or value under the classification
    fhir:Coverage.class.name [ string ]; # 0..1 Display text for an identifier for the group
  ], ...;
  fhir:Coverage.grouping [ # 0..1 Additional coverage classifications
    fhir:Coverage.grouping.group [ string ]; # 0..1 An identifier for the group
    fhir:Coverage.grouping.groupDisplay [ string ]; # 0..1 Display text for an identifier for the group
    fhir:Coverage.grouping.subGroup [ string ]; # 0..1 An identifier for the subsection of the group
    fhir:Coverage.grouping.subGroupDisplay [ string ]; # 0..1 Display text for the subsection of the group
    fhir:Coverage.grouping.plan [ string ]; # 0..1 An identifier for the plan
    fhir:Coverage.grouping.planDisplay [ string ]; # 0..1 Display text for the plan
    fhir:Coverage.grouping.subPlan [ string ]; # 0..1 An identifier for the subsection of the plan
    fhir:Coverage.grouping.subPlanDisplay [ string ]; # 0..1 Display text for the subsection of the plan
    fhir:Coverage.grouping.class [ string ]; # 0..1 An identifier for the class
    fhir:Coverage.grouping.classDisplay [ string ]; # 0..1 Display text for the class
    fhir:Coverage.grouping.subClass [ string ]; # 0..1 An identifier for the subsection of the class
    fhir:Coverage.grouping.subClassDisplay [ string ]; # 0..1 Display text for the subsection of the subclass
  ];
  fhir:Coverage.sequence [ string ]; # 0..1 The plan instance or sequence counter
  fhir:Coverage.order [ positiveInt ]; # 0..1 Relative order of the coverage
  fhir:Coverage.network [ string ]; # 0..1 Insurer network
  fhir:Coverage.copay [ # 0..* Patient payments for services/products
    fhir:Coverage.copay.type [ Coding ]; # 0..1 The type of service or product
    fhir:Coverage.copay.value [ Quantity ]; # 1..1 The amount or percentage of the copayment
  ], ...;
  fhir:Coverage.contract [ Reference(Contract) ], ... ; # 0..* Contract details
]

Changes since DSTU2

Coverage
Coverage.status
  • Added Element
Coverage.type
  • Type changed from Coding to CodeableConcept
Coverage.policyHolder
  • Added Element
Coverage.subscriber
  • Add Reference(RelatedPerson)
  • No longer marked as Modifier
Coverage.subscriberId
  • Type changed from Identifier to string
Coverage.beneficiary
  • Added Element
Coverage.dependent
  • Type changed from positiveInt to string
Coverage.relationship
  • Added Element
Coverage.payor
  • Added Element
Coverage.class
  • Added Element
Coverage.class.type
  • Added Element
Coverage.class.value
  • Added Element
Coverage.class.name
  • Added Element
Coverage.grouping
  • Added Element
Coverage.grouping.group
  • Added Element
Coverage.grouping.groupDisplay
  • Added Element
Coverage.grouping.subGroup
  • Added Element
Coverage.grouping.subGroupDisplay
  • Added Element
Coverage.grouping.plan
  • Added Element
Coverage.grouping.planDisplay
  • Added Element
Coverage.grouping.subPlan
  • Added Element
Coverage.grouping.subPlanDisplay
  • Added Element
Coverage.grouping.class
  • Added Element
Coverage.grouping.classDisplay
  • Added Element
Coverage.grouping.subClass
  • Added Element
Coverage.grouping.subClassDisplay
  • Added Element
Coverage.sequence
  • Type changed from positiveInt to string
Coverage.order
  • Added Element
Coverage.network
  • Type changed from Identifier to string
Coverage.copay
  • Added Element
Coverage.copay.type
  • Added Element
Coverage.copay.value
  • Added Element
Coverage.issuer
  • deleted
Coverage.bin
  • deleted
Coverage.group
  • deleted
Coverage.plan
  • deleted
Coverage.subPlan
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

 

Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions & the dependency analysis

13.1.2.1 Terminology Bindings

PathDefinitionTypeReference
Coverage.status A code specifying the state of the resource instance.RequiredFinancial Resource Status Codes
Coverage.type The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.PreferredCoverage Type and Self-Pay Codes
Coverage.relationship The relationship between the Policyholder and the Beneficiary (insured/covered party/patient).ExamplePolicyholder Relationship Codes
Coverage.class.type The policy classifications, eg. Group, Plan, Class, etc.ExtensibleCoverage Level Codes
Coverage.copay.type The tytpes of services to which patient copayments are specified.ExtensibleCoverage Copay Type Codes

13.1.3 Search Parameters

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

NameTypeDescriptionExpressionIn Common
beneficiaryreferenceCovered partyCoverage.beneficiary
(Patient)
classstringClass identifierCoverage.grouping.class
dependentstringDependent numberCoverage.dependent
groupstringGroup identifierCoverage.grouping.group
identifiertokenThe primary identifier of the insured and the coverageCoverage.identifier
patientreferenceRetrieve coverages for a patientCoverage.beneficiary
(Patient)
payorreferenceThe identity of the insurer or party paying for servicesCoverage.payor
(Organization, Patient, RelatedPerson)
planstringA plan or policy identifierCoverage.grouping.plan
policy-holderreferenceReference to the policyholderCoverage.policyHolder
(Organization, Patient, RelatedPerson)
sequencestringSequence numberCoverage.sequence
statustokenThe status of the CoverageCoverage.status
subclassstringSub-class identifierCoverage.grouping.subClass
subgroupstringSub-group identifierCoverage.grouping.subGroup
subplanstringSub-plan identifierCoverage.grouping.subPlan
subscriberreferenceReference to the subscriberCoverage.subscriber
(Patient, RelatedPerson)
typetokenThe kind of coverage (health plan, auto, Workers Compensation)Coverage.type