R4 Ballot #1 (Mixed Normative/Trial use) Current Build
This page was published as part of FHIR v3.3.0: R4 Ballot #1 : Mixed Normative/Trial use (First Normative ballot). It has been superceded by R4 . For a full list of available versions, see the Directory of published versions .

13.1 Resource Coverage - Content

Financial Management Work Group Maturity Level : 2   Trial Use Security Category : Patient Compartments : Patient , RelatedPerson

Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.

The Coverage resource is intended to provide the high level high-level identifiers and descriptors of an insurance plan plan, typically the information which would appear on an insurance card, which may be used to pay for, pay, in part or in whole, for the provision of health care products and services.

This resource may also be used to register 'SelfPay' where an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs. Selfpay should not be confused with being a guarantor of the patient's account.

The Coverage resource is a "event" resource from a FHIR workflow perspective - see Workflow Request.

The eClaim domain includes a number of related insurance resources

Coverage The Coverage resource is intended to provide the high-level identifiers and descriptors of a specific insurance plan for a specific individual - essentially the insurance card information. This may alternately provide the individual or organization, selfpay, which will pay for products and services rendered.
Contract A Contract resource holds the references to parties who have entered into an agreement of some type, the parties who may sign or witness such an agreement, descriptors of the type of agreement and even the actual text or executable copy of the agreement. The agreement may be of a variety of types including service contracts, insurance contracts, directives, etc. The contract may be either definitional or actual instances.
InsurancePlan The InsurancePlan resource holds the definition of an insurance plan which an insurer may offer to potential clients through insurance brokers or an online insurance marketplace. This is only the plan definition and does not contain or reference a list of individuals who have purchased the plan.

This resource is referenced by Account , Claim , ClaimResponse , DeviceRequest CoverageEligibilityRequest , EligibilityRequest CoverageEligibilityResponse , EligibilityResponse DeviceRequest , EnrollmentRequest , ExplanationOfBenefit , MedicationRequest , ServiceRequest and ServiceRequest Task .

This resource implements the Event pattern.

Structure

Name Flags Card. Type Description & Constraints doco
. . Coverage TU DomainResource Insurance or medical plan or a payment agreement
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ 0..* Identifier The primary Business Identifier for the coverage ID
. . . status ?! Σ 0..1 1..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
. . . type Σ 0..1 CodeableConcept Type of coverage Coverage category such as medical or accident
Coverage Type and Self-Pay Codes ( Preferred )
. . . policyHolder Σ 0..1 Reference ( Patient | RelatedPerson | Organization ) Owner of the policy
. . . subscriber Σ 0..1 Reference ( Patient | RelatedPerson ) Subscriber to the policy
. . . subscriberId Σ 0..1 string ID assigned to the Subscriber subscriber
. . . beneficiary Σ 0..1 1..1 Reference ( Patient ) Plan Beneficiary beneficiary
. . . dependent Σ 0..1 string Dependent number
. . . relationship 0..1 CodeableConcept Beneficiary relationship to the Subscriber subscriber
Policyholder SubscriberPolicyholder Relationship Codes ( Example Extensible )
. . . period Σ 0..1 Period Coverage start and end dates
. . . payor Σ 0..* 1..* Reference ( Organization | Patient | RelatedPerson ) Identifier for Issuer of the plan or agreement issuer policy
. . . class 0..* BackboneElement Additional coverage classifications
. . . . type Σ 1..1 Coding CodeableConcept Type of class such as 'group' or 'plan'
Coverage Class Codes ( Extensible )
. . . . value Σ 1..1 string The tag or value under Value associated with the classification type
. . . . name Σ 0..1 string Display text for an identifier for Human readable description of the group type and value
. . . order Σ 0..1 positiveInt Relative order of the coverage
. . . network Σ 0..1 string Insurer network
. . . copay costToBeneficiary 0..* BackboneElement Patient payments for services/products
. . . . type Σ 0..1 Coding CodeableConcept The type of service or product Cost category
Coverage Copay Type Codes ( Extensible )
. . . . value[x] Σ 1..1 The amount or percentage due from the beneficiary
. . . . . valueQuantity SimpleQuantity
... . . value valueMoney Money
. . . . exception 0..* BackboneElement Exceptions for patient payments
..... type Σ 1..1 Quantity CodeableConcept Exception category
Example Coverage Financial Exception Codes ( Example )
..... period Σ 0..1 Period The amount or percentage effective period of the copayment exception
... subrogation 0..1 boolean Reimbursement to insurer
. . . contract 0..* Reference ( Contract ) Contract details

doco Documentation for this format

UML Diagram ( Legend )

Coverage ( DomainResource ) The main (and possibly only) A unique identifier for the coverage - often referred assigned to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatination of the Coverage.SubscriberID and the Coverage.dependant this coverage identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [0..1] [1..1] « A code specifying the state of the resource instance. (Strength=Required) Financial Resource Status FinancialResourceStatusCodes ! » The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization type : CodeableConcept [0..1] « The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. (Strength=Preferred) Coverage Type and Self-Pay CoverageTypeAndSelf-PayCodes ? » The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer policy policyHolder : Reference [0..1] « Patient | RelatedPerson | Organization » The party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due subscriber : Reference [0..1] « Patient | RelatedPerson » The insurer assigned ID for the Subscriber subscriberId : string [0..1] The party who benefits from the insurance coverage., coverage; the patient when products and/or services are provided beneficiary : Reference [0..1] [1..1] « Patient » A unique identifier for a dependent under the coverage dependent : string [0..1] The relationship of beneficiary (patient) to the subscriber relationship : CodeableConcept [0..1] « The relationship between the Policyholder Subscriber and the Beneficiary (insured/covered party/patient). (Strength=Example) (Strength=Extensible) Policyholder Relationship SubscriberRelationshipCodes ?? + » 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 period : Period [0..1] The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements. May provide multiple identifiers such as insurance company identifier or business identifier (BIN number) agreements payor : Reference [0..*] [1..*] « Organization | Patient | RelatedPerson » The order of applicability of this coverage relative to other coverages which are currently inforce. in force. Note, there may be gaps in the numbering and this does not imply primary, secondard secondary etc. as the specific positioning of coverages depends upon the episode of care order : positiveInt [0..1] The insurer-specific identifier for the insurer-defined network of providers to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply network : string [0..1] When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs subrogation : boolean [0..1] The policy(s) which constitute this insurance coverage contract : Reference [0..*] « Contract » Class The type of classification for which an insurer-specific class tag label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan type : Coding CodeableConcept [1..1] « The policy classifications, eg. Group, Plan, Class, etc. (Strength=Extensible) Coverage Class CoverageClassCodes + » For example The alphanumeric string value associated with the Group or Plan number insurer issued label value : string [1..1] A short description for the class name : string [0..1] CoPay CostToBeneficiary Types The category of products or services such as visit, specialist vists, emergency, inpatient care, etc patient centric costs associated with treatment type : Coding CodeableConcept [0..1] « The tytpes types of services to which patient copayments are specified. (Strength=Extensible) Coverage Copay Type CoverageCopayTypeCodes + » The amount of due from the patient payments for various types of services/products, expressed as a percentage of the service/product cost or a fixed amount of currency, category value value[x] : Quantity Type [1..1] « Quantity ( SimpleQuantity )| Money » Exemption The code for the specific exception type : CodeableConcept [1..1] « The types of exceptions from the part or full value of financial obligations such as copays. (Strength=Example) ExampleCoverageFinancialExcep... ?? » The timeframe during when the exception is in force period : Period [0..1] A suite of underwrite underwriter specific classifiers, for example may be used to identify a classifiers class [0..*] A suite of coverage codes indicating exceptions or employer group, Policy, Plan reductions to patient costs and their effective periods class exception [0..*] A suite of underwrite specific classifiers, for example codes indicating the cost category and associated amount which have been detailed in the policy and may be used to identify a class of coverage or employer group, Policy, Plan have been included on the health card copay costToBeneficiary [0..*]

XML Template

<Coverage xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <
 <</type>
 <</policyHolder>

 <identifier><!-- 0..* Identifier Business Identifier for the coverage --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Coverage category such as medical or accident --></type>
 <policyHolder><!-- 0..1 Reference(Organization|Patient|RelatedPerson) Owner of the policy --></policyHolder>

 <subscriber><!-- 0..1 Reference(Patient|RelatedPerson) Subscriber to the policy --></subscriber>
 <
 <</beneficiary>

 <subscriberId value="[string]"/><!-- 0..1 ID assigned to the subscriber -->
 <beneficiary><!-- 1..1 Reference(Patient) Plan beneficiary --></beneficiary>

 <dependent value="[string]"/><!-- 0..1 Dependent number -->
 <</relationship>

 <relationship><!-- 0..1 CodeableConcept Beneficiary relationship to the subscriber --></relationship>

 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <</payor>
 <
  <</type>
  <
  <

 <payor><!-- 1..* Reference(Organization|Patient|RelatedPerson) Issuer of the policy --></payor>
 <class>  <!-- 0..* Additional coverage classifications -->
  <type><!-- 1..1 CodeableConcept Type of class such as 'group' or 'plan' --></type>
  <value value="[string]"/><!-- 1..1 Value associated with the type -->
  <name value="[string]"/><!-- 0..1 Human readable description of the type and value -->

 </class>
 <

 <order value="[positiveInt]"/><!-- 0..1 Relative order of the coverage -->

 <network value="[string]"/><!-- 0..1 Insurer network -->
 <
  <</type>
  <</value>
 </copay>

 <costToBeneficiary>  <!-- 0..* Patient payments for services/products -->
  <type><!-- 0..1 CodeableConcept Cost category --></type>
  <value[x]><!-- 1..1 Quantity(SimpleQuantity)|Money The amount or percentage due from the beneficiary --></value[x]>
  <exception>  <!-- 0..* Exceptions for patient payments -->
   <type><!-- 1..1 CodeableConcept Exception category --></type>
   <period><!-- 0..1 Period The effective period of the exception --></period>
  </exception>
 </costToBeneficiary>
 <subrogation value="[boolean]"/><!-- 0..1 Reimbursement to insurer -->

 <contract><!-- 0..* Reference(Contract) Contract details --></contract>
</Coverage>

JSON Template

{doco
  "resourceType" : "",

  "resourceType" : "Coverage",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "

  "identifier" : [{ Identifier }], // Business Identifier for the coverage
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Coverage category such as medical or accident
  "policyHolder" : { Reference(Organization|Patient|RelatedPerson) }, // Owner of the policy

  "subscriber" : { Reference(Patient|RelatedPerson) }, // Subscriber to the policy
  "
  "

  "subscriberId" : "<string>", // ID assigned to the subscriber
  "beneficiary" : { Reference(Patient) }, // R!  Plan beneficiary

  "dependent" : "<string>", // Dependent number
  "

  "relationship" : { CodeableConcept }, // Beneficiary relationship to the subscriber

  "period" : { Period }, // Coverage start and end dates
  "
  "
    "
    "
    "

  "payor" : [{ Reference(Organization|Patient|RelatedPerson) }], // R!  Issuer of the policy
  "class" : [{ // Additional coverage classifications
    "type" : { CodeableConcept }, // R!  Type of class such as 'group' or 'plan'
    "value" : "<string>", // R!  Value associated with the type
    "name" : "<string>" // Human readable description of the type and value

  }],
  "

  "order" : "<positiveInt>", // Relative order of the coverage

  "network" : "<string>", // Insurer network
  "
    "
    "

  "costToBeneficiary" : [{ // Patient payments for services/products
    "type" : { CodeableConcept }, // Cost category
    // value[x]: The amount or percentage due from the beneficiary. One of these 2:
    "valueQuantity" : { Quantity(SimpleQuantity) },
    "valueMoney" : { Money },
    "exception" : [{ // Exceptions for patient payments
      "type" : { CodeableConcept }, // R!  Exception category
      "period" : { Period } // The effective period of the exception
    }]

  }],
  "subrogation" : <boolean>, // Reimbursement to insurer

  "contract" : [{ Reference(Contract) }] // Contract details
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco
[ a fhir:;

[ a fhir:Coverage;

  fhir:nodeRole fhir:treeRoot; # if this is the parser root
  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:
  fhir:
  fhir:
  fhir:

  fhir:Coverage.identifier [ Identifier ], ... ; # 0..* Business Identifier for the coverage
  fhir:Coverage.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:Coverage.type [ CodeableConcept ]; # 0..1 Coverage category such as medical or accident
  fhir:Coverage.policyHolder [ Reference(Organization|Patient|RelatedPerson) ]; # 0..1 Owner of the policy

  fhir:Coverage.subscriber [ Reference(Patient|RelatedPerson) ]; # 0..1 Subscriber to the policy
  fhir:
  fhir:

  fhir:Coverage.subscriberId [ string ]; # 0..1 ID assigned to the subscriber
  fhir:Coverage.beneficiary [ Reference(Patient) ]; # 1..1 Plan beneficiary

  fhir:Coverage.dependent [ string ]; # 0..1 Dependent number
  fhir:

  fhir:Coverage.relationship [ CodeableConcept ]; # 0..1 Beneficiary relationship to the subscriber

  fhir:Coverage.period [ Period ]; # 0..1 Coverage start and end dates
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:

  fhir:Coverage.payor [ Reference(Organization|Patient|RelatedPerson) ], ... ; # 1..* Issuer of the policy
  fhir:Coverage.class [ # 0..* Additional coverage classifications
    fhir:Coverage.class.type [ CodeableConcept ]; # 1..1 Type of class such as 'group' or 'plan'
    fhir:Coverage.class.value [ string ]; # 1..1 Value associated with the type
    fhir:Coverage.class.name [ string ]; # 0..1 Human readable description of the type and value

  ], ...;
  fhir:

  fhir:Coverage.order [ positiveInt ]; # 0..1 Relative order of the coverage

  fhir:Coverage.network [ string ]; # 0..1 Insurer network
  fhir:
    fhir:
    fhir:

  fhir:Coverage.costToBeneficiary [ # 0..* Patient payments for services/products
    fhir:Coverage.costToBeneficiary.type [ CodeableConcept ]; # 0..1 Cost category
    # Coverage.costToBeneficiary.value[x] : 1..1 The amount or percentage due from the beneficiary. One of these 2
      fhir:Coverage.costToBeneficiary.valueSimpleQuantity [ Quantity(SimpleQuantity) ]
      fhir:Coverage.costToBeneficiary.valueMoney [ Money ]
    fhir:Coverage.costToBeneficiary.exception [ # 0..* Exceptions for patient payments
      fhir:Coverage.costToBeneficiary.exception.type [ CodeableConcept ]; # 1..1 Exception category
      fhir:Coverage.costToBeneficiary.exception.period [ Period ]; # 0..1 The effective period of the exception
    ], ...;

  ], ...;
  fhir:Coverage.subrogation [ boolean ]; # 0..1 Reimbursement to insurer

  fhir:Coverage.contract [ Reference(Contract) ], ... ; # 0..* Contract details
]

Changes since R3

Coverage.class Added Element Coverage.class.type Added Element Coverage.class.value Added Element Coverage.class.name Added Element Coverage.copay Added Element Coverage.copay.type Added Element
Coverage
Coverage.copay.value Coverage.status
  • Added Element Change value set from http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to http://hl7.org/fhir/ValueSet/fm-status|4.1.0
Coverage.grouping Coverage.costToBeneficiary.value[x]
  • deleted Add Type Quantity()
  • Coverage.sequence
  • deleted Remove Type Quantity()

See the Full Difference for further information

This analysis is available as XML or JSON .

See R3 <--> R4 Conversion Maps (status = 4 tests that all execute ok. 1 fail round-trip testing and all r3 resources are valid.)

Structure

Name Flags Card. Type Description & Constraints doco
. . Coverage TU DomainResource Insurance or medical plan or a payment agreement
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ 0..* Identifier The primary Business Identifier for the coverage ID
. . . status ?! Σ 0..1 1..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
. . . type Σ 0..1 CodeableConcept Type of coverage Coverage category such as medical or accident
Coverage Type and Self-Pay Codes ( Preferred )
. . . policyHolder Σ 0..1 Reference ( Patient | RelatedPerson | Organization ) Owner of the policy
. . . subscriber Σ 0..1 Reference ( Patient | RelatedPerson ) Subscriber to the policy
. . . subscriberId Σ 0..1 string ID assigned to the Subscriber subscriber
. . . beneficiary Σ 0..1 1..1 Reference ( Patient ) Plan Beneficiary beneficiary
. . . dependent Σ 0..1 string Dependent number
. . . relationship 0..1 CodeableConcept Beneficiary relationship to the Subscriber subscriber
Policyholder SubscriberPolicyholder Relationship Codes ( Example Extensible )
. . . period Σ 0..1 Period Coverage start and end dates
. . . payor Σ 0..* 1..* Reference ( Organization | Patient | RelatedPerson ) Identifier for Issuer of the plan or agreement issuer policy
. . . class 0..* BackboneElement Additional coverage classifications
. . . . type Σ 1..1 Coding CodeableConcept Type of class such as 'group' or 'plan'
Coverage Class Codes ( Extensible )
. . . . value Σ 1..1 string The tag or value under Value associated with the classification type
. . . . name Σ 0..1 string Display text for an identifier for Human readable description of the group type and value
. . . order Σ 0..1 positiveInt Relative order of the coverage
. . . network Σ 0..1 string Insurer network
. . . copay costToBeneficiary 0..* BackboneElement Patient payments for services/products
. . . . type Σ 0..1 Coding CodeableConcept The type of service or product Cost category
Coverage Copay Type Codes ( Extensible )
. . . . value[x] Σ 1..1 The amount or percentage due from the beneficiary
..... valueQuantity SimpleQuantity
. . . . . value valueMoney Money
. . . . exception 0..* BackboneElement Exceptions for patient payments
..... type Σ 1..1 Quantity CodeableConcept Exception category
Example Coverage Financial Exception Codes ( Example )
..... period Σ 0..1 Period The amount or percentage effective period of the copayment exception
... subrogation 0..1 boolean Reimbursement to insurer
. . . contract 0..* Reference ( Contract ) Contract details

doco Documentation for this format

UML Diagram ( Legend )

Coverage ( DomainResource ) The main (and possibly only) A unique identifier for the coverage - often referred assigned to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatination of the Coverage.SubscriberID and the Coverage.dependant this coverage identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [0..1] [1..1] « A code specifying the state of the resource instance. (Strength=Required) Financial Resource Status FinancialResourceStatusCodes ! » The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization type : CodeableConcept [0..1] « The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. (Strength=Preferred) Coverage Type and Self-Pay CoverageTypeAndSelf-PayCodes ? » The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer policy policyHolder : Reference [0..1] « Patient | RelatedPerson | Organization » The party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due subscriber : Reference [0..1] « Patient | RelatedPerson » The insurer assigned ID for the Subscriber subscriberId : string [0..1] The party who benefits from the insurance coverage., coverage; the patient when products and/or services are provided beneficiary : Reference [0..1] [1..1] « Patient » A unique identifier for a dependent under the coverage dependent : string [0..1] The relationship of beneficiary (patient) to the subscriber relationship : CodeableConcept [0..1] « The relationship between the Policyholder Subscriber and the Beneficiary (insured/covered party/patient). (Strength=Example) (Strength=Extensible) Policyholder Relationship SubscriberRelationshipCodes ?? + » 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 period : Period [0..1] The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements. May provide multiple identifiers such as insurance company identifier or business identifier (BIN number) agreements payor : Reference [0..*] [1..*] « Organization | Patient | RelatedPerson » The order of applicability of this coverage relative to other coverages which are currently inforce. in force. Note, there may be gaps in the numbering and this does not imply primary, secondard secondary etc. as the specific positioning of coverages depends upon the episode of care order : positiveInt [0..1] The insurer-specific identifier for the insurer-defined network of providers to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply network : string [0..1] When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs subrogation : boolean [0..1] The policy(s) which constitute this insurance coverage contract : Reference [0..*] « Contract » Class The type of classification for which an insurer-specific class tag label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan type : Coding CodeableConcept [1..1] « The policy classifications, eg. Group, Plan, Class, etc. (Strength=Extensible) Coverage Class CoverageClassCodes + » For example The alphanumeric string value associated with the Group or Plan number insurer issued label value : string [1..1] A short description for the class name : string [0..1] CoPay CostToBeneficiary Types The category of products or services such as visit, specialist vists, emergency, inpatient care, etc patient centric costs associated with treatment type : Coding CodeableConcept [0..1] « The tytpes types of services to which patient copayments are specified. (Strength=Extensible) Coverage Copay Type CoverageCopayTypeCodes + » The amount of due from the patient payments for various types of services/products, expressed as a percentage of the service/product cost or a fixed amount of currency, category value value[x] : Quantity Type [1..1] « Quantity ( SimpleQuantity )| Money » Exemption The code for the specific exception type : CodeableConcept [1..1] « The types of exceptions from the part or full value of financial obligations such as copays. (Strength=Example) ExampleCoverageFinancialExcep... ?? » The timeframe during when the exception is in force period : Period [0..1] A suite of underwrite underwriter specific classifiers, for example may be used to identify a classifiers class [0..*] A suite of coverage codes indicating exceptions or employer group, Policy, Plan reductions to patient costs and their effective periods class exception [0..*] A suite of underwrite specific classifiers, for example codes indicating the cost category and associated amount which have been detailed in the policy and may be used to identify a class of coverage or employer group, Policy, Plan have been included on the health card copay costToBeneficiary [0..*]

XML Template

<Coverage xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <
 <</type>
 <</policyHolder>

 <identifier><!-- 0..* Identifier Business Identifier for the coverage --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Coverage category such as medical or accident --></type>
 <policyHolder><!-- 0..1 Reference(Organization|Patient|RelatedPerson) Owner of the policy --></policyHolder>

 <subscriber><!-- 0..1 Reference(Patient|RelatedPerson) Subscriber to the policy --></subscriber>
 <
 <</beneficiary>

 <subscriberId value="[string]"/><!-- 0..1 ID assigned to the subscriber -->
 <beneficiary><!-- 1..1 Reference(Patient) Plan beneficiary --></beneficiary>

 <dependent value="[string]"/><!-- 0..1 Dependent number -->
 <</relationship>

 <relationship><!-- 0..1 CodeableConcept Beneficiary relationship to the subscriber --></relationship>

 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <</payor>
 <
  <</type>
  <
  <

 <payor><!-- 1..* Reference(Organization|Patient|RelatedPerson) Issuer of the policy --></payor>
 <class>  <!-- 0..* Additional coverage classifications -->
  <type><!-- 1..1 CodeableConcept Type of class such as 'group' or 'plan' --></type>
  <value value="[string]"/><!-- 1..1 Value associated with the type -->
  <name value="[string]"/><!-- 0..1 Human readable description of the type and value -->

 </class>
 <

 <order value="[positiveInt]"/><!-- 0..1 Relative order of the coverage -->

 <network value="[string]"/><!-- 0..1 Insurer network -->
 <
  <</type>
  <</value>
 </copay>

 <costToBeneficiary>  <!-- 0..* Patient payments for services/products -->
  <type><!-- 0..1 CodeableConcept Cost category --></type>
  <value[x]><!-- 1..1 Quantity(SimpleQuantity)|Money The amount or percentage due from the beneficiary --></value[x]>
  <exception>  <!-- 0..* Exceptions for patient payments -->
   <type><!-- 1..1 CodeableConcept Exception category --></type>
   <period><!-- 0..1 Period The effective period of the exception --></period>
  </exception>
 </costToBeneficiary>
 <subrogation value="[boolean]"/><!-- 0..1 Reimbursement to insurer -->

 <contract><!-- 0..* Reference(Contract) Contract details --></contract>
</Coverage>

JSON Template

{doco
  "resourceType" : "",

  "resourceType" : "Coverage",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "

  "identifier" : [{ Identifier }], // Business Identifier for the coverage
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Coverage category such as medical or accident
  "policyHolder" : { Reference(Organization|Patient|RelatedPerson) }, // Owner of the policy

  "subscriber" : { Reference(Patient|RelatedPerson) }, // Subscriber to the policy
  "
  "

  "subscriberId" : "<string>", // ID assigned to the subscriber
  "beneficiary" : { Reference(Patient) }, // R!  Plan beneficiary

  "dependent" : "<string>", // Dependent number
  "

  "relationship" : { CodeableConcept }, // Beneficiary relationship to the subscriber

  "period" : { Period }, // Coverage start and end dates
  "
  "
    "
    "
    "

  "payor" : [{ Reference(Organization|Patient|RelatedPerson) }], // R!  Issuer of the policy
  "class" : [{ // Additional coverage classifications
    "type" : { CodeableConcept }, // R!  Type of class such as 'group' or 'plan'
    "value" : "<string>", // R!  Value associated with the type
    "name" : "<string>" // Human readable description of the type and value

  }],
  "

  "order" : "<positiveInt>", // Relative order of the coverage

  "network" : "<string>", // Insurer network
  "
    "
    "

  "costToBeneficiary" : [{ // Patient payments for services/products
    "type" : { CodeableConcept }, // Cost category
    // value[x]: The amount or percentage due from the beneficiary. One of these 2:
    "valueQuantity" : { Quantity(SimpleQuantity) },
    "valueMoney" : { Money },
    "exception" : [{ // Exceptions for patient payments
      "type" : { CodeableConcept }, // R!  Exception category
      "period" : { Period } // The effective period of the exception
    }]

  }],
  "subrogation" : <boolean>, // Reimbursement to insurer

  "contract" : [{ Reference(Contract) }] // Contract details
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco
[ a fhir:;

[ a fhir:Coverage;

  fhir:nodeRole fhir:treeRoot; # if this is the parser root
  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:
  fhir:
  fhir:
  fhir:

  fhir:Coverage.identifier [ Identifier ], ... ; # 0..* Business Identifier for the coverage
  fhir:Coverage.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:Coverage.type [ CodeableConcept ]; # 0..1 Coverage category such as medical or accident
  fhir:Coverage.policyHolder [ Reference(Organization|Patient|RelatedPerson) ]; # 0..1 Owner of the policy

  fhir:Coverage.subscriber [ Reference(Patient|RelatedPerson) ]; # 0..1 Subscriber to the policy
  fhir:
  fhir:

  fhir:Coverage.subscriberId [ string ]; # 0..1 ID assigned to the subscriber
  fhir:Coverage.beneficiary [ Reference(Patient) ]; # 1..1 Plan beneficiary

  fhir:Coverage.dependent [ string ]; # 0..1 Dependent number
  fhir:

  fhir:Coverage.relationship [ CodeableConcept ]; # 0..1 Beneficiary relationship to the subscriber

  fhir:Coverage.period [ Period ]; # 0..1 Coverage start and end dates
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:

  fhir:Coverage.payor [ Reference(Organization|Patient|RelatedPerson) ], ... ; # 1..* Issuer of the policy
  fhir:Coverage.class [ # 0..* Additional coverage classifications
    fhir:Coverage.class.type [ CodeableConcept ]; # 1..1 Type of class such as 'group' or 'plan'
    fhir:Coverage.class.value [ string ]; # 1..1 Value associated with the type
    fhir:Coverage.class.name [ string ]; # 0..1 Human readable description of the type and value

  ], ...;
  fhir:

  fhir:Coverage.order [ positiveInt ]; # 0..1 Relative order of the coverage

  fhir:Coverage.network [ string ]; # 0..1 Insurer network
  fhir:
    fhir:
    fhir:

  fhir:Coverage.costToBeneficiary [ # 0..* Patient payments for services/products
    fhir:Coverage.costToBeneficiary.type [ CodeableConcept ]; # 0..1 Cost category
    # Coverage.costToBeneficiary.value[x] : 1..1 The amount or percentage due from the beneficiary. One of these 2
      fhir:Coverage.costToBeneficiary.valueSimpleQuantity [ Quantity(SimpleQuantity) ]
      fhir:Coverage.costToBeneficiary.valueMoney [ Money ]
    fhir:Coverage.costToBeneficiary.exception [ # 0..* Exceptions for patient payments
      fhir:Coverage.costToBeneficiary.exception.type [ CodeableConcept ]; # 1..1 Exception category
      fhir:Coverage.costToBeneficiary.exception.period [ Period ]; # 0..1 The effective period of the exception
    ], ...;

  ], ...;
  fhir:Coverage.subrogation [ boolean ]; # 0..1 Reimbursement to insurer

  fhir:Coverage.contract [ Reference(Contract) ], ... ; # 0..* Contract details
]

Changes since DSTU2 Release 3

Coverage.class Added Element Coverage.class.type Added Element Coverage.class.value Added Element Coverage.class.name Added Element Coverage.copay Added Element Coverage.copay.type Added Element
Coverage
Coverage.copay.value Coverage.status
  • Added Element Change value set from http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to http://hl7.org/fhir/ValueSet/fm-status|4.1.0
Coverage.grouping Coverage.costToBeneficiary.value[x]
  • deleted Add Type Quantity()
  • Coverage.sequence
  • deleted Remove Type Quantity()

See the Full Difference for further information

This analysis is available as XML or JSON .

See R3 <--> R4 Conversion Maps (status = 4 tests that all execute ok. 1 fail round-trip testing and all r3 resources are valid.)

 

Alternate See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON , XML Schema / Schematron + JSON Schema , ShEx (for Turtle ) + see the extensions , the spreadsheet version & the dependency analysis a

Path Definition Type Reference
Coverage.status A code specifying the state of the resource instance. Required Financial Resource Status Codes FinancialResourceStatusCodes
Coverage.type The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. Preferred Coverage Type and Self-Pay Codes CoverageTypeAndSelf-PayCodes
Coverage.relationship The relationship between the Policyholder Subscriber and the Beneficiary (insured/covered party/patient). Example Extensible Policyholder Relationship Codes SubscriberRelationshipCodes
Coverage.class.type The policy classifications, eg. Group, Plan, Class, etc. Extensible Coverage Class Codes CoverageClassCodes
Coverage.copay.type Coverage.costToBeneficiary.type The tytpes types of services to which patient copayments are specified. Extensible Coverage Copay Type Codes CoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.type The types of exceptions from the part or full value of financial obligations such as copays. Example ExampleCoverageFinancialExceptionCodes

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
beneficiary reference Covered party Coverage.beneficiary
( Patient )
class-type token Coverage class (eg. plan, group) Coverage.class.type
class-value string Value of the class (eg. Plan number, group number) Coverage.class.value
dependent string Dependent number Coverage.dependent
identifier token The primary identifier of the insured and the coverage Coverage.identifier
patient reference Retrieve coverages for a patient Coverage.beneficiary
( Patient )
payor reference The identity of the insurer or party paying for services Coverage.payor
( Organization , Patient , RelatedPerson )
policy-holder reference Reference to the policyholder Coverage.policyHolder
( Organization , Patient , RelatedPerson )
status token The status of the Coverage Coverage.status
subscriber reference Reference to the subscriber Coverage.subscriber
( Patient , RelatedPerson )
type token The kind of coverage (health plan, auto, Workers Compensation) Coverage.type