type: resource-definitionsresource: Coverage

Coverage Definitions

Coverage

Insurance or medical plan or a payment agreement

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

Comments: The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.

Cardinality: 0..*

Mappings: workflow=Event; rim=Coverage; w5=financial.support

Coverage.identifier

Business identifier(s) for this coverage

Definition: The identifier of the coverage as issued by the insurer.

Comments: 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.

Requirements: Allows coverages to be distinguished and referenced.

Cardinality: 0..*

Type: Identifier

Summary: true

Mappings: workflow=Event.identifier; w5=FiveWs.identifier; cdanetv4=C02; rim=.id; cpha3pharm=C.32, C.33, C.39

Coverage.status

active | cancelled | draft | entered-in-error

Definition: 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.

Comments: This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.

Requirements: Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Cardinality: 1..1

Type: code

Binding: required:fm-status

Summary: true

Is Modifier: true (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)

Mappings: workflow=Event.status; w5=FiveWs.status; rim=Act.status

Coverage.statusReason

Reason for status change

Definition: Used to indicate why the status has changed.

Comments: Implementation guides may consider adding invariants such that if status = cancelled, statusReason SHALL be supplied.

Requirements: This is used to implement conformance on other elements.

Cardinality: 0..1

Type: string

Summary: true

Coverage.kind

insurance | self-pay | other

Definition: The nature of the coverage be it insurance, or cash payment such as self-pay.

Requirements: This is used to implement conformance on other elements.

Cardinality: 1..1

Type: code

Binding: required:coverage-kind

Summary: true

Constraints: cov-self-pay-1 | error | When patient is self-pay, paymentBy must exist. | %resource.kind = 'self-pay' implies (%resource.insurer.empty() and %resource.paymentBy.exists()); cov-insured-1 | error | When patient is insured, insurer must exist. | %resource.kind = 'insurance' implies (%resource.insurer.exists() and %resource.paymentBy.empty())

Coverage.paymentBy

Self-pay parties and responsibility

Definition: Link to the paying party and optionally what specifically they will be responsible to pay.

Conditions: cov-insured-1, cov-self-pay-1

Cardinality: 0..*

Type: BackboneElement

Coverage.paymentBy.party

Parties performing self-payment

Definition: The list of parties providing non-insurance payment for the treatment costs.

Cardinality: 1..1

Type: Reference(Patient, RelatedPerson, Organization)

Summary: true

Coverage.paymentBy.responsibility

Party's responsibility

Definition: Description of the financial responsibility.

Cardinality: 0..1

Type: string

Summary: true

Coverage.type

Coverage category such as medical or accident

Definition: The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.

Requirements: The order of application of coverages is dependent on the types of coverage.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:coverage-type

Summary: true

Mappings: w5=FiveWs.class; v2=IN1-15

Coverage.policyHolder

Owner of the policy

Definition: The party who 'owns' the insurance policy.

Comments: For example: may be an individual, corporation or the subscriber's employer.

Requirements: This provides employer information in the case of Worker's Compensation and other policies.

Cardinality: 0..1

Type: Reference(Patient, RelatedPerson, Organization)

Summary: true

Mappings: w5=FiveWs.subject; cdanetv4=D01 through D09; v2=IN1-16, 18, 19-name of insured, address, date of birth; cpha3pharm=C.35

Coverage.subscriber

Subscriber to the policy

Definition: 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.

Comments: May be self or a parent in the case of dependents. A subscriber is only required on certain types of policies not all policies and that it is appropriate to have just a policyholder and a beneficiary when no other party can join that policy instance.

Requirements: This is the party who is entitled to the benfits under the policy.

Cardinality: 0..1

Type: Reference(Patient, RelatedPerson)

Summary: true

Mappings: w5=FiveWs.subject; cdanetv4=D01 through D09; v2=IN1-16, 18, 19-name of insured, address, date of birth; cpha3pharm=C.35

Coverage.subscriberId

ID assigned to the subscriber

Definition: The insurer assigned ID for the Subscriber.

Requirements: The insurer requires this identifier on correspondance and claims (digital and otherwise).

Cardinality: 0..*

Type: Identifier

Summary: true

Mappings: w5=FiveWs.subject; cdanetv4=D01 through D09; v2=IN1-16, 18, 19-name of insured, address, date of birth; cpha3pharm=C.35

Coverage.beneficiary

Plan beneficiary

Definition: The party who benefits from the insurance coverage; the patient when products and/or services are provided.

Requirements: This is the party who receives treatment for which the costs are reimbursed under the coverage.

Cardinality: 1..1

Type: Reference(Patient)

Summary: true

Mappings: workflow=Event.subject; w5=FiveWs.subject; cdanetv4=D01 through D09; v2=IN1-16, 18, 19-name of insured, address, date of birth; cpha3pharm=C.35

Coverage.dependent

Dependent number

Definition: A designator for a dependent under the coverage.

Comments: Sometimes the member number is constructed from the subscriberId and the dependent number.

Requirements: For some coverages a single identifier is issued to the Subscriber and then an additional dependent number is issued to each beneficiary.

Cardinality: 0..1

Type: string

Summary: true

Mappings: cdanetv4=C17; v2=- No exact HL7 V2 equivalent concept seems to exist;

Coverage.relationship

Beneficiary relationship to the subscriber

Definition: The relationship of beneficiary (patient) to the subscriber.

Comments: Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.

Requirements: The relationship between the patient and the subscriber to determine coordination of benefits.

Cardinality: 0..1

Type: CodeableConcept

Binding: extensible:subscriber-relationship

Mappings: cdanetv4=C03

Coverage.period

Coverage start and end dates

Definition: 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.

Requirements: Some insurers require the submission of the coverage term.

Cardinality: 0..1

Type: Period

Summary: true

Mappings: workflow=Event.occurrence[x]; w5=FiveWs.done[x]; v2=IN1-12 / IN1-13; rim=Act.effectiveTime

Coverage.insurer

Issuer of the policy

Definition: The program or plan underwriter, payor, insurance company.

Comments: May provide multiple identifiers such as insurance company identifier or business identifier (BIN number).

Requirements: Need to identify the issuer to target for claim processing and for coordination of benefit processing.

Conditions: cov-insured-1, cov-self-pay-1

Cardinality: 0..1

Type: Reference(Organization)

Summary: true

Coverage.class

Additional coverage classifications

Definition: A suite of underwriter specific classifiers.

Comments: For example, class may be used to identify a class of coverage or employer group, policy, or plan.

Requirements: The codes provided on the health card which identify or confirm the specific policy for the insurer.

Cardinality: 0..*

Type: BackboneElement

Coverage.class.type

Type of class such as 'group' or 'plan'

Definition: The type of classification for which an insurer-specific class label or number and optional name is provided. For example, type may be used to identify a class of coverage or employer group, policy, or plan.

Requirements: The insurer issued label for a specific health card value.

Cardinality: 1..1

Type: CodeableConcept

Binding: extensible:coverage-class

Summary: true

Coverage.class.value

Value associated with the type

Definition: The alphanumeric identifier associated with the insurer issued label.

Comments: For example, the Group or Plan number.

Requirements: The insurer issued label and identifier are necessary to identify the specific policy, group, etc..

Cardinality: 1..1

Type: Identifier

Summary: true

Mappings: cdanetv4=C11 (Division,Section); v2=IN1-8; v2=IN1-2; cpha3pharm=C.31

Coverage.class.name

Human readable description of the type and value

Definition: A short description for the class.

Requirements: Used to provide a meaningful description in correspondence to the patient.

Cardinality: 0..1

Type: string

Summary: true

Mappings: cdanetv4=C11 (Division,Section); v2=IN1-8; cpha3pharm=C.31

Coverage.order

Relative order of the coverage

Definition: The order of applicability of this coverage relative to other coverages which are currently in force. Note, there may be gaps in the numbering and this does not imply primary, secondary etc. as the specific positioning of coverages depends upon the episode of care. For example; a patient might have (0) auto insurance (1) their own health insurance and (2) spouse's health insurance. When claiming for treatments which were not the result of an auto accident then only coverages (1) and (2) above would be applicable and would apply in the order specified in parenthesis. Coverage.order conveys the Coordination of Benefit (COB) ordering of coverage independent of use-case, for a use-case dependent set of Coverages see Account.coverage.priority.

Requirements: Used in managing the coordination of benefits.

Cardinality: 0..1

Type: positiveInt

Summary: true

Coverage.network

Insurer network

Definition: 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.

Requirements: Used in referral for treatment and in claims processing.

Cardinality: 0..1

Type: string

Summary: true

Mappings: cdanetv4=D10

Coverage.costToBeneficiary

Patient payments for services/products

Definition: A suite of codes indicating the cost category and associated amount which have been detailed in the policy and may have been included on the health card.

Comments: For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.

Requirements: Required by providers to manage financial transaction with the patient.

Aliases: CoPay, Deductible, Exceptions

Cardinality: 0..*

Type: BackboneElement

Coverage.costToBeneficiary.type

Cost category

Definition: The category of patient centric costs associated with treatment.

Comments: For example visit, specialist visits, emergency, inpatient care, etc.

Requirements: Needed to identify the category associated with the amount for the patient.

Cardinality: 0..1

Type: CodeableConcept

Binding: extensible:coverage-copay-type

Summary: true

Coverage.costToBeneficiary.category

Benefit classification

Definition: Code to identify the general type of benefits under which products and services are provided.

Comments: Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Requirements: Needed to convey the category of service or product for which eligibility is sought.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-benefitcategory

Coverage.costToBeneficiary.network

In or out of network

Definition: Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.

Requirements: Needed as in or out of network providers are treated differently under the coverage.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:benefit-network

Coverage.costToBeneficiary.unit

Individual or family

Definition: Indicates if the benefits apply to an individual or to the family.

Requirements: Needed for the understanding of the benefits.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:benefit-unit

Coverage.costToBeneficiary.term

Annual or lifetime

Definition: The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.

Requirements: Needed for the understanding of the benefits.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:benefit-term

Coverage.costToBeneficiary.value[x]

The amount or percentage due from the beneficiary

Definition: The amount due from the patient for the cost category.

Comments: Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.

Requirements: Needed to identify the amount for the patient associated with the category.

Cardinality: 0..1

Type: Quantity(SimpleQuantity), Money

Summary: true

Mappings: cdanetv4=C11 (Division,Section); v2=IN1-8; cpha3pharm=C.31

Coverage.costToBeneficiary.exception

Exceptions for patient payments

Definition: A suite of codes indicating exceptions or reductions to patient costs and their effective periods.

Requirements: Required by providers to manage financial transaction with the patient.

Cardinality: 0..*

Type: BackboneElement

Coverage.costToBeneficiary.exception.type

Exception category

Definition: The code for the specific exception.

Requirements: Needed to identify the exception associated with the amount for the patient.

Cardinality: 1..1

Type: CodeableConcept

Binding: example:coverage-financial-exception

Summary: true

Coverage.costToBeneficiary.exception.period

The effective period of the exception

Definition: The timeframe the exception is in force.

Requirements: Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs.

Cardinality: 0..1

Type: Period

Summary: true

Coverage.subrogation

Reimbursement to insurer

Definition: When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs.

Comments: Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.

Requirements: See definition for when to be used.

Cardinality: 0..1

Type: boolean

Coverage.contract

Contract details

Definition: The policy(s) which constitute this insurance coverage.

Requirements: To reference the legally binding contract between the policy holder and the insurer.

Cardinality: 0..*

Type: Reference(Contract)

Mappings: cdanetv4=D01 through D09; v2=IN1-16, 18, 19; rim=n/a; cpha3pharm=C.35

Coverage.insurancePlan

Insurance plan details

Definition: The insurance plan details, benefits and costs, which constitute this insurance coverage.

Requirements: To associate the plan benefits and costs with the coverage which is an instance of that plan.

Cardinality: 0..1

Type: Reference(InsurancePlan)