---
type: "resource-definitions"
title: "Coverage Definitions"
resource: "Coverage"
---

# Coverage Definitions

<a id="Coverage"></a>

## 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


<a id="Coverage.identifier"></a>

## 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](/Identifier)

**Summary:** true

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


<a id="Coverage.status"></a>

## 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](/code)

**Binding:** required:[fm-status](/valueset-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


<a id="Coverage.statusReason"></a>

## 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](/string)

**Summary:** true


<a id="Coverage.kind"></a>

## 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](/code)

**Binding:** required:[coverage-kind](/valueset-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())


<a id="Coverage.paymentBy"></a>

## 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](/BackboneElement)


<a id="Coverage.paymentBy.party"></a>

## 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](/Patient), [RelatedPerson](/RelatedPerson), [Organization](/Organization))

**Summary:** true


<a id="Coverage.paymentBy.responsibility"></a>

## Coverage.paymentBy.responsibility
Party's responsibility

**Definition:** Description of the financial responsibility.

**Cardinality:** 0..1

**Type:** [string](/string)

**Summary:** true


<a id="Coverage.type"></a>

## 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](/CodeableConcept)

**Binding:** preferred:[coverage-type](/valueset-coverage-type)

**Summary:** true

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


<a id="Coverage.policyHolder"></a>

## 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](/Patient), [RelatedPerson](/RelatedPerson), [Organization](/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


<a id="Coverage.subscriber"></a>

## 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](/Patient), [RelatedPerson](/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


<a id="Coverage.subscriberId"></a>

## 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](/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


<a id="Coverage.beneficiary"></a>

## 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](/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


<a id="Coverage.dependent"></a>

## 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](/string)

**Summary:** true

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


<a id="Coverage.relationship"></a>

## 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](/CodeableConcept)

**Binding:** extensible:[subscriber-relationship](/valueset-subscriber-relationship)

**Mappings:** cdanetv4=C03


<a id="Coverage.period"></a>

## 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](/Period)

**Summary:** true

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


<a id="Coverage.insurer"></a>

## 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](/Organization))

**Summary:** true


<a id="Coverage.class"></a>

## 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](/BackboneElement)


<a id="Coverage.class.type"></a>

## 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](/CodeableConcept)

**Binding:** extensible:[coverage-class](/valueset-coverage-class)

**Summary:** true


<a id="Coverage.class.value"></a>

## 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](/Identifier)

**Summary:** true

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


<a id="Coverage.class.name"></a>

## 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](/string)

**Summary:** true

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


<a id="Coverage.order"></a>

## 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](/positiveInt)

**Summary:** true


<a id="Coverage.network"></a>

## 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](/string)

**Summary:** true

**Mappings:** cdanetv4=D10


<a id="Coverage.costToBeneficiary"></a>

## 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](/BackboneElement)


<a id="Coverage.costToBeneficiary.type"></a>

## 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](/CodeableConcept)

**Binding:** extensible:[coverage-copay-type](/valueset-coverage-copay-type)

**Summary:** true


<a id="Coverage.costToBeneficiary.category"></a>

## 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](/CodeableConcept)

**Binding:** example:[ex-benefitcategory](/valueset-ex-benefitcategory)


<a id="Coverage.costToBeneficiary.network"></a>

## 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](/CodeableConcept)

**Binding:** preferred:[benefit-network](/valueset-benefit-network)


<a id="Coverage.costToBeneficiary.unit"></a>

## 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](/CodeableConcept)

**Binding:** preferred:[benefit-unit](/valueset-benefit-unit)


<a id="Coverage.costToBeneficiary.term"></a>

## 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](/CodeableConcept)

**Binding:** preferred:[benefit-term](/valueset-benefit-term)


<a id="Coverage.costToBeneficiary.value[x]"></a>

## 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](/Quantity)([SimpleQuantity](/SimpleQuantity)), [Money](/Money)

**Summary:** true

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


<a id="Coverage.costToBeneficiary.exception"></a>

## 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](/BackboneElement)


<a id="Coverage.costToBeneficiary.exception.type"></a>

## 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](/CodeableConcept)

**Binding:** example:[coverage-financial-exception](/valueset-coverage-financial-exception)

**Summary:** true


<a id="Coverage.costToBeneficiary.exception.period"></a>

## 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](/Period)

**Summary:** true


<a id="Coverage.subrogation"></a>

## 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](/boolean)


<a id="Coverage.contract"></a>

## 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](/Contract))

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


<a id="Coverage.insurancePlan"></a>

## 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](/InsurancePlan))