This page is part of the Da Vinci Payer Data Exchange (v2.0.0-ballot: STU2 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

Coverage

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The Coverage resource is profiled in the Da Vinci HRex IG.

NOTE: This resource is not included in the resource set returned by Payer-to-Payer exchange. The resource is used to submit coverage information to the $MemberMatch operation.

The essential fields (Must Support or Cardinality greater than 0..*) to be provided in the HRex Coverage resource are:

R4 Element	Name	Cardinality	Type
Coverage.identifier	identifier	0..*	Identifier
Coverage.status	status	1..1	code
Coverage.subscriberId	subscriberId	0..1	string
Coverage.beneficiary	beneficiary	1..1	Reference(US Core Patient Profile)
Coverage.payor	payor	1..*	Reference(HRex Organization Profile)

Table Definition

Health Plan Mapping Assistance

A collaboration of Health Plan experts have performed an evaluation of claims information and developed a mapping of data for Members to the Coverage profile. This is shown below as an assistance to implementers:

US Core Element	Must Support	Cardinality	CARIN-BB Element	CPCDS Element Mapping or Implementer Note
Coverage.meta.lastUpdated		0..1	Coverage.meta.lastUpdated	[{“163”:”Coverage Last Updated Date”}]
Coverage.identifier	S	0..*	Coverage.identifier	Supply a Unique Coverage Identifier
Coverage.status		1..1	Coverage.status	[{“133”:”Coverage status”}]
Coverage.subscriberId	S	0..1	Coverage.subscriberId	[{“132”:”Subscriber id”}]
Coverage.beneficiary	S	1..1	Coverage.beneficiary	[{“Ref (1)”:”Member id”}
Coverage.relationship		0..1	Coverage.relationship	[{“72”:”Relationship to subscriber”}]
Coverage.payor	S	1..*	Coverage.payor	[{“Ref (2) ”:”Claim Payer Identifier”}
Coverage.class.value		1..1	Coverage.class.value	[{“Plan=154”:”Plan Identifier”}, {“Group=134”:”Group Id”}
Coverage.class.name		0..1	Coverage.class.name	[{“Plan=155”:”Plan Name”}, {“Group=135”:”Group Name”}

Table Definition

It is important to note a difference between Coverage information provided in the CARIN-BB IG and the PDex IG. The PDex IG Coverage expresses the current state of health plan coverage whereas the CARIN-BB Coverage is intended to express the coverage that was valid at the date of service or admission.

SubscriberId may not uniquely identify a health plan member. If beneficiary is subscriber, also set .relationship to “self”.

It may, for example, identify the parent who obtains coverage for a child. Therefore, the Coverage resource may provide a combination of identifiers and point to demographic information to uniquely identify a patient/member.

Coverage.identifier MAY include a member identifier in the Coverage resource.

Example Coverage Resource

An example mapping of a Coverage resource is shown here:

{
  "resourceType": "Coverage",
  "id": "9876B1",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the coverage</div>"
  },
  "identifier": [
    {
      "system": "http://benefitsinc.com/certificate",
      "value": "12345"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code": "EHCPOL",
        "display": "extended healthcare"
      }
    ]
  },
  "policyHolder": {
    "reference": "http://benefitsinc.com/FHIR/Organization/CBI35"
  },
  "subscriber": {
    "reference": "Patient/4"
  },
  "beneficiary": {
    "reference": "Patient/4"
  },
  "dependent": "0",
  "relationship": {
    "coding": [
      {
        "code": "self"
      }
    ]
  },
  "period": {
    "start": "2011-05-23",
    "end": "2012-05-23"
  },
  "payor": [
    {
      "reference": "Organization/Payer1"
    }
  ],
  "class": [
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "group"
          }
        ]
      },
      "value": "CB135",
      "name": "Corporate Baker's Inc. Local #35"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "subgroup"
          }
        ]
      },
      "value": "123",
      "name": "Trainee Part-time Benefits"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "plan"
          }
        ]
      },
      "value": "B37FC",
      "name": "Full Coverage: Medical, Dental, Pharmacy, Vision, EHC"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "subplan"
          }
        ]
      },
      "value": "P7",
      "name": "Includes afterlife benefits"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "class"
          }
        ]
      },
      "value": "SILVER",
      "name": "Silver: Family Plan spouse only"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "subclass"
          }
        ]
      },
      "value": "Tier2",
      "name": "Low deductable, max $20 copay"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "sequence"
          }
        ]
      },
      "value": "9"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "rxid"
          }
        ]
      },
      "value": "MDF12345"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "rxbin"
          }
        ]
      },
      "value": "987654"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "rxgroup"
          }
        ]
      },
      "value": "M35PT"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "rxpcn"
          }
        ]
      },
      "value": "234516"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "sequence"
          }
        ]
      },
      "value": "9"
    }
  ]
}

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