This page is part of the CARIN Digital Insurance Card (v2.0.0-ballot: STU2 Ballot) based on FHIR (HL7® FHIR® Standard) R4. This version is a pre-release. The current official version is 1.1.0. For a full list of available versions, see the Directory of published versions

Use Cases

Page standards status: Informative

This section has been restructured into a multi-page section to support the addition of a significant number of new use cases for the use of Digital Insurance Card.

Terms and Concepts

Term	Definition
Subscriber	An individual or entity that selects benefits offered by an entity, such as an employer, government, or insurance company
Dependent	An individual, other than the subscriber, who has insurance coverage under the benefits selected by a subscriber
Member	Any individual covered by the benefits offered by an entity, such as an employer or insurance company. In the US, some government programs refer to Members as Beneficiaries.
Patient	An individual who has received, is receiving or intends to receive health care services. (Health care services as defined by federal and state regulations.)
Personal Representative	Per the HIPAA privacy regulations at 45 CFR 164.502(g), a personal-representative is someone authorized under state or other applicable law to act on behalf of the individual in making health care related decisions (such as a parent, guardian, or person with a medical power of attorney)
Payer	Public or private party which offers and/or administers health insurance plan(s) or coverage and/or pays claims directly or indirectly. Examples include: - Insurance Company - Health Maintenance Organization - Medicare - Third-party Administrator - Repricer

Use Cases

This Implementation Guide provides both foundational and specific use cases for a Digital Insurance Card. The Foundational use case describe basic capabilities, such as initiating a Digital Insurance enabled transaction. Other use case are specific examples of exchanges, such as utilizing a Digital Insurance Card to enable a Real-Time Pharmacy Benefit Check.

Foundational Use Cases

• Authorization
• Distribution
• Patient Access API
• Representing Multiple Coverages for the Same Payer
• Support for Multiple Digital Insurance cards

Insurance Card Transaction Examples

• Consumer Access to their Insurance Card Data
• Consumer Access and Exchange
• Real-Time Pharmacy Benefit Check
• Comparison with International Patient Summary IG
• Summary of Benefits and Coverage