Coverage

Introduction

Scope and Usage

The Coverage resource is intended to provide the high-level identifiers and descriptors of an insurance plan, typically the information which would appear on an insurance card, which may be used to 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.

Boundaries and Relationships

The eClaim domain includes a number of related insurance resources

StructureDefinition

Elements (Simplified)

• Coverage [0..*]: - Insurance or medical plan or a payment agreement
• Coverage.identifier [0..*]: Identifier Business identifier(s) for this coverage
• Coverage.status [1..1]: code required:fm-status active | cancelled | draft | entered-in-error
• Coverage.statusReason [0..1]: string Reason for status change
• Coverage.kind [1..1]: code required:coverage-kind insurance | self-pay | other
• Coverage.paymentBy [0..*]: BackboneElement Self-pay parties and responsibility
• Coverage.paymentBy.party [1..1]: [Reference(Patient](/Reference(Patient), RelatedPerson, Organization)) Parties performing self-payment
• Coverage.paymentBy.responsibility [0..1]: string Party's responsibility
• Coverage.type [0..1]: CodeableConcept preferred:coverage-type Coverage category such as medical or accident
• Coverage.policyHolder [0..1]: [Reference(Patient](/Reference(Patient), RelatedPerson, Organization)) Owner of the policy
• Coverage.subscriber [0..1]: [Reference(Patient](/Reference(Patient), RelatedPerson)) Subscriber to the policy
• Coverage.subscriberId [0..*]: Identifier ID assigned to the subscriber
• Coverage.beneficiary [1..1]: Reference(Patient) Plan beneficiary
• Coverage.dependent [0..1]: string Dependent number
• Coverage.relationship [0..1]: CodeableConcept extensible:subscriber-relationship Beneficiary relationship to the subscriber
• Coverage.period [0..1]: Period Coverage start and end dates
• Coverage.insurer [0..1]: Reference(Organization) Issuer of the policy
• Coverage.class [0..*]: BackboneElement Additional coverage classifications
• Coverage.class.type [1..1]: CodeableConcept extensible:coverage-class Type of class such as 'group' or 'plan'
• Coverage.class.value [1..1]: Identifier Value associated with the type
• Coverage.class.name [0..1]: string Human readable description of the type and value
• Coverage.order [0..1]: positiveInt Relative order of the coverage
• Coverage.network [0..1]: string Insurer network
• Coverage.costToBeneficiary [0..*]: BackboneElement Patient payments for services/products
• Coverage.costToBeneficiary.type [0..1]: CodeableConcept extensible:coverage-copay-type Cost category
• Coverage.costToBeneficiary.category [0..1]: CodeableConcept example:ex-benefitcategory Benefit classification
• Coverage.costToBeneficiary.network [0..1]: CodeableConcept preferred:benefit-network In or out of network
• Coverage.costToBeneficiary.unit [0..1]: CodeableConcept preferred:benefit-unit Individual or family
• Coverage.costToBeneficiary.term [0..1]: CodeableConcept preferred:benefit-term Annual or lifetime
• Coverage.costToBeneficiary.value[x] [0..1]: Quantity(SimpleQuantity), Money The amount or percentage due from the beneficiary
• Coverage.costToBeneficiary.exception [0..*]: BackboneElement Exceptions for patient payments
• Coverage.costToBeneficiary.exception.type [1..1]: CodeableConcept example:coverage-financial-exception Exception category
• Coverage.costToBeneficiary.exception.period [0..1]: Period The effective period of the exception
• Coverage.subrogation [0..1]: boolean Reimbursement to insurer
• Coverage.contract [0..*]: Reference(Contract) Contract details
• Coverage.insurancePlan [0..1]: Reference(InsurancePlan) Insurance plan details

Mappings

• Coverage Mappings — 52 mapping entries

Resource Packs

list-Coverage-packs.xml

<?xml version="1.0" encoding="UTF-8"?>

<List xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../publish/List.xsd">
  <id value="Coverage-packs"/>
  <status value="current"/>
  <mode value="working"/>
</List>

Search Parameters

• beneficiary — reference — Covered party — Coverage.beneficiary
• class-type — token — Coverage class (e.g. plan, group) — Coverage.class.type
• class-value — token — Value of the class (e.g. 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
• paymentby-party — reference — Parties who will pay for services — Coverage.paymentBy.party
• period — date — Dates that the Coverage is active — Coverage.period
• insurer — reference — The identity of the insurer — Coverage.insurer
• policy-holder — reference — Reference to the policyholder — Coverage.policyHolder
• status — token — The status of the Coverage — Coverage.status
• subscriber — reference — Reference to the subscriber — Coverage.subscriber
• subscriberid — token — Identifier of the subscriber — Coverage.subscriberId
• type — token — The kind of coverage (health plan, auto, Workers Compensation) — Coverage.type

Full Search Parameters

Examples

• 7546D — coverage-example-2 — General Person Secondary Coverage Example
• 7547E — coverage-example-ehic — European Health Insurance Card
• 9876B1 — coverage-example — General Person Primary Coverage Example
• coverage-example — coverage-example
• coverage-example-2 — coverage-example-2
• coverage-example-ehic — coverage-example-ehic
• coverage-example-selfpay — coverage-example-selfpay
• coverage-examples-header — coverage-examples-header
• SP1234 — coverage-example-selfpay — Self Payment Example

Full Examples

Mapping Exceptions

coverage-event-mapping-exceptions.xml

Divergent Elements

• Event.identifier → Coverage.identifier
  • shortUnmatched | reason=Unknown | pattern=Business identifier for coverage | resource=Business identifier(s) for this coverage
  • definitionUnmatched | reason=Unknown | pattern=Business identifiers assigned to this coverage by the performer and/or other systems. These identifiers remain constant as the resource is updated and propagates from server to server. | resource=The identifier of the coverage as issued by the insurer.
  • commentsUnmatched | reason=Unknown | pattern=Note: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. | resource=The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependent. Note that not all insurers issue unique member IDs therefore searches may result in multiple responses.
  • requirementsUnmatched | reason=Unknown | pattern=Allows identification of the coverage as it is known by various participating systems and in a way that remains consistent across servers. | resource=Allows coverages to be distinguished and referenced.
• Event.status → Coverage.status
  • shortUnmatched | reason=Unknown | pattern=preparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown | resource=active | cancelled | draft | entered-in-error
  • definitionUnmatched | reason=Unknown | pattern=The current state of the coverage. | resource=The status of the resource instance. The status element does not indicate whether the policy reflected in the instance is in-force at any particular point in time, that would be conveyed via the 'period' element.
  • commentsUnmatched | reason=Unknown | pattern=A nominal state-transition diagram can be found in the (Event pattern documentation

Unknown does not represent "other" - one of the defined statuses must apply. Unknown is used when the authoring system is not sure what the current status is. | resource=This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.

• Event.subject → Coverage.beneficiary
  • missingTypes | reason=Unknown | pattern=Reference(Group)
  • shortUnmatched | reason=Unknown | pattern=Individual service was done for/to | resource=Plan beneficiary
  • definitionUnmatched | reason=Unknown | pattern=The individual or set of individuals the action is being or was performed on. | resource=The party who benefits from the insurance coverage; the patient when products and/or services are provided.
  • requirementsUnmatched | reason=Unknown | pattern=Links the coverage to the Patient context. May also affect access control. | resource=This is the party who receives treatment for which the costs are reimbursed under the coverage.
• Event.occurrence[x] → Coverage.period
  • missingTypes | reason=Unknown | pattern=dateTime, Timing
  • shortUnmatched | reason=Unknown | pattern=When coverage occurred/is occurring | resource=Coverage start and end dates
  • definitionUnmatched | reason=Unknown | pattern=The date, period or timing when the coverage did occur or is occurring. | resource=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. When non-contiguous periods of coverage need to be documented it is recommended that this is accomplished through the use of an extension,rather than complicating coverage period calculations for many users of the Coverage resource.
  • commentsUnmatched | reason=Unknown | pattern=This indicates when the activity actually occurred or is occurring, not when it was asked/requested/ordered to occur. For the latter, look at the occurence element of the Request this {{event}} is "basedOn". The status code allows differentiation of whether the timing reflects a historic event or an ongoing event. Ongoing events should not include an upper bound in the Period or Timing.bounds. .

Unmapped Elements

• Event.partOf — Unknown
• Event.reported — Unknown
• Event.reason — Unknown
• Event.relevantHistory — Unknown
• Event.code — Unknown
• Event.location — Unknown
• Event.statusReason — Unknown
• Event.performer.actor — Unknown
• Event.performer.function — Unknown
• Event.note — Unknown
• Event.category — Unknown
• Event.encounter — Unknown
• Event.recorded — Unknown
• Event.product — Unknown
• Event.performer — Unknown
• Event.researchStudy — Unknown

coverage-fivews-mapping-exceptions.xml

Unmapped Elements

• FiveWs.what — Unknown
• FiveWs.recorded — Unknown
• FiveWs.author — Unknown
• FiveWs.actor — Unknown
• FiveWs.cause — Unknown
• FiveWs.version — Unknown
• FiveWs.witness — Unknown
• FiveWs.where — Unknown
• FiveWs.context — Unknown
• FiveWs.init — Unknown
• FiveWs.why — Unknown
• FiveWs.source — Unknown
• FiveWs.who — Unknown
• FiveWs.grade — Unknown
• FiveWs.planned — Unknown