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7.3.4 Resource Coverage - Detailed Descriptions

Detailed Descriptions for the elements in the Coverage resource.

Coverage
Definition

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

Control1..1
Requirements

Health care programs and insurers are significant payors of health service costs.

Coverage.issuer
Definition

The program or plan underwriter or payor.

Control0..1
TypeReference(Organization)
Requirements

Need to identify the issuer to target for processing and for coordination of benefit processing.

Summarytrue
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.

Control0..1
TypeIdentifier
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.

Control0..1
TypePeriod
Summarytrue
Coverage.type
Definition

The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health.

Control0..1
BindingCoverageType: The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) (Example)
TypeCoding
Requirements

The order of application of coverages is dependent on the types of coverage.

Summarytrue
Coverage.subscriberId
Definition

The id issued to the subscriber.

Control0..1
TypeIdentifier
Summarytrue
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.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below.

Summarytrue
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.

Control0..1
Typestring
Summarytrue
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.

Control0..1
Typestring
Summarytrue
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.

Control0..1
Typestring
Summarytrue
Coverage.dependent
Definition

A unique identifier for a dependent under the coverage.

Control0..1
Typeinteger
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.

Summarytrue
Coverage.sequence
Definition

An optional counter for a particular instance of the identified coverage which increments upon each renewal.

Control0..1
Typeinteger
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'.

Summarytrue
Coverage.subscriber
Definition

The party who 'owns' the insurance contractual relationship to the policy or to whom the benefit of the policy is due.

Control0..1
TypeReference(Patient)
Is Modifiertrue
To DoD01 through D09.
Coverage.network
Definition

The identifier for a community of providers.

Control0..1
TypeIdentifier
Summarytrue
Coverage.contract
Definition

The policy(s) which constitute this insurance coverage.

Control0..*
TypeReference(Contract)
To DoD01 through D09.