This page is part of the CARIN Digital Insurance Card (v0.1.0: STU 1 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

Background

Introduction

This Implementation Guide was born out of the CARIN Alliance Payer's Implementer Forum where representatives from major health insurance companies in the US come together to collaborate on FHIR server implementation. In 2020, participants of the forum indicated a need for better guidance on how to represent the full data elements found on physical insurance cards within a FHIR-based transaction. In particular, participating payers noted the following challenges when trying to build out FHIR Coverage resources including all the necessary data elements:

• The base Coverage resource allows for representation of the patient for whom the Coverage resource pertains as well as the subscriber. There is not a standard way to represent all of the beneficiaries for the plan and their corresponding member IDs the way they would be found on a physical insurance card.
• The Coverage resource “network” field allows for only one single string. There is a need to allow for a unique identifier for the network as well as a consumer-friendly name which is often printed on the physical insurance card.
• The Coverage resource does not allow for expression of copays in the form of text strings. Some copays are able to represented as the required SimpleQuantity or Money data types while others require strings.
• There is a need to standardize how images often found on insurance cards are able to be expressed in a FHIR-based transaction in a way that is predictable and renderable by consuming applications.

Overview

Payers can leverage the Coverage resource, the Organization resource, and the Patient resource to represent the essential information found on the physicial insurance card. The purpose of each resource is as follows:

• The Coverage resource communicates the insurance plan information
• The Organization resource communicates the contact information for the plan (often found on the back of the physical insurance card)
• The Patient resource communicates additional demographic information such as date of birth for the member whose data is being retrieved

The below diagram outlines how these resources relate. As shown below, the coverage.payor field will contain a reference to the corresponding Organization resource, and the coverage.beneficiary field will contain a reference to the corresponding Patient resource for the member whose data is being retrieved.

Additional Information

For additional information about the exchange of insurance card information please visit these pages:

• Use Case
• Physical Insurance Card Data Elements

Boundaries

This Implementation Guide enables the digital exchange and digital rendering of the elements found on a person’s physical insurance card. The primary use case is to support insurance members who wish to retrieve their current proof of insurance coverage digitally via a consumer-facing application.

This IG does NOT address eligibility checks between health providers and the insurance company.

This IG is not intended to replace use of any existing standards for pharmacy insurance cards, i.e. NCPDP standards, and is being provided to augment existing physical insurance cards where pharmacy benefits may need to be included with other coverage.

In keeping with the 80/20 rule, this IG does not solve for all possible insurance card data elements. If additional data elements of interest are identified by the community, they will be integrated in STU2 of this IG. For example, there are a few unique fields relevant to Medicare cards that were unable to be incorporated into this initial IG development cycle (i.e. CMS Contract Number, PBP Code, Segment ID).