FHIR Release 3 (STU) Current Build
This page is part of FHIR STU 3 (v3.0.1) in it's permanent home (it will always be available at this URL). It has been superceded by R4 .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 potentially 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 , EligibilityRequest CoverageEligibilityRequest , EligibilityResponse CoverageEligibilityResponse , DeviceRequest , EnrollmentRequest , ExplanationOfBenefit , MedicationRequest , ServiceRequest and ExplanationOfBenefit 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
. . . grouping class 0..1 0..* BackboneElement Additional coverage classifications
. . . group . type Σ 0..1 1..1 string CodeableConcept An identifier for the group Type of class such as 'group' or 'plan'
Coverage Class Codes ( Extensible )
. . . . groupDisplay value Σ 0..1 1..1 string Display text for an identifier for Value associated with the group type
. . . . subGroup name Σ 0..1 string An identifier for the subsection Human readable description of the group type and value
. . . subGroupDisplay order Σ 0..1 string positiveInt Display text for the subsection Relative order of the group coverage
. . . plan network Σ 0..1 string An identifier for the plan Insurer network
. . planDisplay . costToBeneficiary Σ 0..1 0..* string BackboneElement Display text Patient payments for the plan services/products
. . . subPlan . type Σ 0..1 string CodeableConcept An identifier for the subsection of the plan subPlanDisplay Cost category
Coverage Copay Type Codes Σ 0..1 string ( Extensible Display text for the subsection of the plan )
. . . class . value[x] Σ 0..1 1..1 string An identifier for The amount or percentage due from the class beneficiary
. . classDisplay . . . valueQuantity Σ 0..1 string SimpleQuantity Display text for the class
. . . subClass . . valueMoney Σ 0..1 string Money An identifier for the subsection of the class
. . . subClassDisplay . exception Σ 0..1 0..* string BackboneElement Display text Exceptions for the subsection of the subclass patient payments
. . . . dependent . type Σ 0..1 1..1 string CodeableConcept Dependent number sequence Exception category
Example Coverage Financial Exception Codes Σ 0..1 string ( Example The plan instance or sequence counter )
. . order . . . period Σ 0..1 positiveInt Period Relative order The effective period of the coverage exception
. . . network subrogation Σ 0..1 string boolean Insurer network 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 » A unique identifier for a dependent under the coverage dependent : string [0..1] An optional counter for a particular instance of the identified coverage which increments upon each renewal sequence : string [0..1] 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 » Group Class Identifies a style or collective The type of coverage issued by the underwriter, classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify an employer group. May also be referred to as a Policy class of coverage or Group ID employer group, Policy, Plan group type : string CodeableConcept [0..1] [1..1] « A short description for the group The policy classifications, eg. Group, Plan, Class, etc. (Strength=Extensible) groupDisplay : string CoverageClassCodes [0..1] + » Identifies a style or collective of coverage issued by The alphanumeric string value associated with the underwriter, for example may be used to identify a subset of an employer group insurer issued label subGroup value : string [0..1] [1..1] A short description for the subgroup class subGroupDisplay name : string [0..1] CostToBeneficiary Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a collection The category of benefits provided to employees. May be referred to as a Section or Division ID patient centric costs associated with treatment plan type : string CodeableConcept [0..1] « The types of services to which patient copayments are specified. (Strength=Extensible) CoverageCopayTypeCodes + » A short description The amount due from the patient for the plan cost category planDisplay value[x] : string Type [0..1] [1..1] « Quantity ( SimpleQuantity )| Money » Identifies a sub-style or sub-collective of coverage issued by the underwriter, for example may be used to identify a subset of a collection of benefits provided to employees subPlan : string [0..1] Exemption A short description The code for the subplan specific exception subPlanDisplay type : string CodeableConcept [0..1] [1..1] « Identifies a style or collective The types of coverage issues by exceptions from the underwriter, for example may be used to identify a class part or full value of coverage financial obligations such as a level of deductables or co-payment copays. (Strength=Example) class : string ExampleCoverageFinancialExcep... [0..1] ?? » A short description for The timeframe during when the class exception is in force classDisplay period : string Period [0..1] Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a subclass of coverage such as a sub-level A suite of deductables or co-payment underwriter specific classifiers subClass : string class [0..1] [0..*] A short description for the subclass suite of codes indicating exceptions or reductions to patient costs and their effective periods subClassDisplay : string exception [0..1] [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 grouping costToBeneficiary [0..1] [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>
 <</relationship>
 <</period>
 <</payor>
 <
  <
  <
  <
  <
  <
  <
  <
  <
  <
  <
  <
  <
 </grouping>

 <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><!-- 0..1 CodeableConcept Beneficiary relationship to the subscriber --></relationship>
 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <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 -->
 <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:
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    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:

  fhir:Coverage.relationship [ CodeableConcept ]; # 0..1 Beneficiary relationship to the subscriber
  fhir:Coverage.period [ Period ]; # 0..1 Coverage start and end dates
  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:Coverage.order [ positiveInt ]; # 0..1 Relative order of the coverage

  fhir:Coverage.network [ string ]; # 0..1 Insurer network
  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 R3

Coverage Coverage.status Added Element
Coverage.type Coverage.status
  • Type changed Change value set from Coding http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to CodeableConcept Coverage.policyHolder Added Element http://hl7.org/fhir/ValueSet/fm-status|4.1.0
Coverage.subscriber Coverage.costToBeneficiary.value[x]
  • Add Reference(RelatedPerson) No longer marked as Modifier Coverage.subscriberId Type changed from Identifier to string Coverage.beneficiary Added Element Coverage.relationship Added Element Coverage.payor Added Element Coverage.grouping Added Element Coverage.grouping.group Added Element Coverage.grouping.groupDisplay Added Element Coverage.grouping.subGroup Added Element Coverage.grouping.subGroupDisplay Added Element Coverage.grouping.plan Added Element Coverage.grouping.planDisplay Added Element Coverage.grouping.subPlan Added Element Coverage.grouping.subPlanDisplay Added Element Coverage.grouping.class Added Element Coverage.grouping.classDisplay Added Element Coverage.grouping.subClass Added Element Coverage.grouping.subClassDisplay Added Element Coverage.dependent Type changed from positiveInt to string Coverage.sequence Type changed from positiveInt to string Coverage.order Added Element Quantity()
  • Coverage.network
  • Remove Type changed from Identifier to string Coverage.issuer deleted Coverage.bin deleted Coverage.group deleted Coverage.plan deleted Coverage.subPlan deleted 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
. . . grouping class 0..1 0..* BackboneElement Additional coverage classifications
. . . group . type Σ 0..1 1..1 string CodeableConcept An identifier for the group Type of class such as 'group' or 'plan'
Coverage Class Codes ( Extensible )
. . . . groupDisplay value Σ 0..1 1..1 string Display text for an identifier for Value associated with the group type
. . . . subGroup name Σ 0..1 string An identifier for the subsection Human readable description of the group type and value
. . . subGroupDisplay order Σ 0..1 string positiveInt Display text for the subsection Relative order of the group coverage
. . . plan network Σ 0..1 string An identifier for the plan Insurer network
. . planDisplay . costToBeneficiary Σ 0..1 0..* string BackboneElement Display text Patient payments for the plan services/products
. . . subPlan . type Σ 0..1 string CodeableConcept An identifier for the subsection of the plan subPlanDisplay Cost category
Coverage Copay Type Codes Σ 0..1 string ( Extensible Display text for the subsection of the plan )
. . . class . value[x] Σ 0..1 1..1 string An identifier for The amount or percentage due from the class beneficiary
. . classDisplay . . . valueQuantity Σ 0..1 string SimpleQuantity Display text for the class
. . . subClass . . valueMoney Σ 0..1 string Money An identifier for the subsection of the class
. . . subClassDisplay . exception Σ 0..1 0..* string BackboneElement Display text Exceptions for the subsection of the subclass patient payments
. . . . dependent . type Σ 0..1 1..1 string CodeableConcept Dependent number sequence Exception category
Example Coverage Financial Exception Codes Σ 0..1 string ( Example The plan instance or sequence counter )
. . order . . . period Σ 0..1 positiveInt Period Relative order The effective period of the coverage exception
. . . network subrogation Σ 0..1 string boolean Insurer network 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 » A unique identifier for a dependent under the coverage dependent : string [0..1] An optional counter for a particular instance of the identified coverage which increments upon each renewal sequence : string [0..1] 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 » Group Class Identifies a style or collective The type of coverage issued by the underwriter, classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify an employer group. May also be referred to as a Policy class of coverage or Group ID employer group, Policy, Plan group type : string CodeableConcept [0..1] [1..1] « A short description for the group The policy classifications, eg. Group, Plan, Class, etc. (Strength=Extensible) groupDisplay : string CoverageClassCodes [0..1] + » Identifies a style or collective of coverage issued by The alphanumeric string value associated with the underwriter, for example may be used to identify a subset of an employer group insurer issued label subGroup value : string [0..1] [1..1] A short description for the subgroup class subGroupDisplay name : string [0..1] CostToBeneficiary Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a collection The category of benefits provided to employees. May be referred to as a Section or Division ID patient centric costs associated with treatment plan type : string CodeableConcept [0..1] « The types of services to which patient copayments are specified. (Strength=Extensible) CoverageCopayTypeCodes + » A short description The amount due from the patient for the plan cost category planDisplay value[x] : string Type [0..1] [1..1] « Quantity ( SimpleQuantity )| Money » Identifies a sub-style or sub-collective of coverage issued by the underwriter, for example may be used to identify a subset of a collection of benefits provided to employees subPlan : string [0..1] Exemption A short description The code for the subplan specific exception subPlanDisplay type : string CodeableConcept [0..1] [1..1] « Identifies a style or collective The types of coverage issues by exceptions from the underwriter, for example may be used to identify a class part or full value of coverage financial obligations such as a level of deductables or co-payment copays. (Strength=Example) class : string ExampleCoverageFinancialExcep... [0..1] ?? » A short description for The timeframe during when the class exception is in force classDisplay period : string Period [0..1] Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a subclass of coverage such as a sub-level A suite of deductables or co-payment underwriter specific classifiers subClass : string class [0..1] [0..*] A short description for the subclass suite of codes indicating exceptions or reductions to patient costs and their effective periods subClassDisplay : string exception [0..1] [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 grouping costToBeneficiary [0..1] [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>
 <</relationship>
 <</period>
 <</payor>
 <
  <
  <
  <
  <
  <
  <
  <
  <
  <
  <
  <
  <
 </grouping>

 <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><!-- 0..1 CodeableConcept Beneficiary relationship to the subscriber --></relationship>
 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <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 -->
 <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:
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    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:

  fhir:Coverage.relationship [ CodeableConcept ]; # 0..1 Beneficiary relationship to the subscriber
  fhir:Coverage.period [ Period ]; # 0..1 Coverage start and end dates
  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:Coverage.order [ positiveInt ]; # 0..1 Relative order of the coverage

  fhir:Coverage.network [ string ]; # 0..1 Insurer network
  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 Coverage.status Added Element
Coverage.type Coverage.status
  • Type changed Change value set from Coding http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to CodeableConcept Coverage.policyHolder Added Element http://hl7.org/fhir/ValueSet/fm-status|4.1.0
Coverage.subscriber Coverage.costToBeneficiary.value[x]
  • Add Reference(RelatedPerson) No longer marked as Modifier Coverage.subscriberId Type changed from Identifier to string Coverage.beneficiary Added Element Coverage.relationship Added Element Coverage.payor Added Element Coverage.grouping Added Element Coverage.grouping.group Added Element Coverage.grouping.groupDisplay Added Element Coverage.grouping.subGroup Added Element Coverage.grouping.subGroupDisplay Added Element Coverage.grouping.plan Added Element Coverage.grouping.planDisplay Added Element Coverage.grouping.subPlan Added Element Coverage.grouping.subPlanDisplay Added Element Coverage.grouping.class Added Element Coverage.grouping.classDisplay Added Element Coverage.grouping.subClass Added Element Coverage.grouping.subClassDisplay Added Element Coverage.dependent Type changed from positiveInt to string Coverage.sequence Type changed from positiveInt to string Coverage.order Added Element Quantity()
  • Coverage.network
  • Remove Type changed from Identifier to string Coverage.issuer deleted Coverage.bin deleted Coverage.group deleted Coverage.plan deleted Coverage.subPlan deleted 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 (for ) + 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). Extensible SubscriberRelationshipCodes
Coverage.class.type The policy classifications, eg. Group, Plan, Class, etc. Extensible CoverageClassCodes
Coverage.costToBeneficiary.type The types of services to which patient copayments are specified. Extensible CoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.type The types of exceptions from the part or full value of financial obligations such as copays. Example Policyholder Relationship Codes 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 class-type string token Class identifier Coverage class (eg. plan, group) Coverage.grouping.class Coverage.class.type
dependent class-value string Dependent number Value of the class (eg. Plan number, group number) Coverage.dependent Coverage.class.value
group dependent string Group identifier Dependent number Coverage.grouping.group 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 )
plan string A plan or policy identifier Coverage.grouping.plan policy-holder reference Reference to the policyholder Coverage.policyHolder
( Organization , Patient , RelatedPerson )
sequence string Sequence number Coverage.sequence subclass string Sub-class identifier Coverage.grouping.subClass subgroup string Sub-group identifier Coverage.grouping.subGroup subplan status string token Sub-plan identifier The status of the Coverage Coverage.grouping.subPlan 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