This page is part of the Da Vinci Payer Data Exchange (v2.1.0-ballot: STU2.1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

Coverage

Page standards status: Informative

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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..1	Identifier
Coverage.status	status	1..1	code
Coverage.subscriberId	subscriberId	0..1	string
Coverage.beneficiary	beneficiary	1..1	Reference(HRex Patient Demographics Profile)
Coverage.payor	payor	1..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:

PDex 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	[{"Ref (1)":"Member id"}]
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	Use [{"Ref (1)":"Member id"}] to find Ratient/id Reference
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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