Current Build
Financial Management Work GroupMaturity Level: 2 Trial Use Compartments: Patient, RelatedPerson

Detailed Descriptions for the elements in the Coverage resource.

Coverage
Element IdCoverage
Definition

Financial instrument which may be used to reimburse or pay for health care products and services.

Control1..1
Requirements

Health care programs and insurers are significant payors of health service costs.

Coverage.identifier
Element IdCoverage.identifier
Definition

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.dependant.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below.

Summarytrue
Coverage.status
Element IdCoverage.status
Definition

The status of the resource instance.

Control0..1
Terminology BindingFinancial Resource Status Codes (Required)
Typecode
Is Modifiertrue (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)
Summarytrue
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.

Coverage.type
Element IdCoverage.type
Definition

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

Control0..1
Terminology BindingCoverage Type and Self-Pay Codes (Preferred)
TypeCodeableConcept
Requirements

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

Summarytrue
Coverage.policyHolder
Element IdCoverage.policyHolder
Definition

The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer.

Control0..1
TypeReference(Patient | RelatedPerson | Organization)
Summarytrue
Coverage.subscriber
Element IdCoverage.subscriber
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.

Control0..1
TypeReference(Patient | RelatedPerson)
Summarytrue
Coverage.subscriberId
Element IdCoverage.subscriberId
Definition

The insurer assigned ID for the Subscriber.

Control0..1
Typestring
Summarytrue
Coverage.beneficiary
Element IdCoverage.beneficiary
Definition

The party who benefits from the insurance coverage; the patient when services are provided.

Control0..1
TypeReference(Patient)
Summarytrue
Coverage.dependent
Element IdCoverage.dependent
Definition

A unique identifier for a dependent under the coverage.

Control0..1
Typestring
Requirements

For some coverage a single identifier is issued to the Subscriber and a dependent number issued to each beneficiary.

Summarytrue
Coverage.relationship
Element IdCoverage.relationship
Definition

The relationship of beneficiary (patient) to the subscriber.

Control0..1
Terminology BindingPolicyholder Relationship Codes (Example)
TypeCodeableConcept
Requirements

To determine relationship between the patient and the subscriber.

Coverage.period
Element IdCoverage.period
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.

Control0..1
TypePeriod
Summarytrue
Coverage.payor
Element IdCoverage.payor
Definition

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).

Control0..*
TypeReference(Organization | Patient | RelatedPerson)
Requirements

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

Summarytrue
Coverage.class
Element IdCoverage.class
Definition

A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan.

Control0..*
Coverage.class.type
Element IdCoverage.class.type
Definition

The type of classification for which an insurer-specific class tag or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan.

Control1..1
Terminology BindingCoverage Class Codes (Extensible)
TypeCoding
Summarytrue
Coverage.class.value
Element IdCoverage.class.value
Definition

For example, the Group or Plan number.

Control1..1
Typestring
Summarytrue
Coverage.class.name
Element IdCoverage.class.name
Definition

A short description for the class.

Control0..1
Typestring
Summarytrue
Coverage.order
Element IdCoverage.order
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.

Control0..1
TypepositiveInt
Summarytrue
Coverage.network
Element IdCoverage.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.

Control0..1
Typestring
Summarytrue
Coverage.copay
Element IdCoverage.copay
Definition

A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan.

Control0..*
Coverage.copay.type
Element IdCoverage.copay.type
Definition

Types of products or services such as visit, specialist visits, emergency, inpatient care, etc.

Control0..1
Terminology BindingCoverage Copay Type Codes (Extensible)
TypeCoding
Summarytrue
Coverage.copay.value
Element IdCoverage.copay.value
Definition

The amount of patient payments for various types of services/products, expressed as a percentage of the service/product cost or a fixed amount of currency.

Control1..1
TypeQuantity
Summarytrue
Coverage.contract
Element IdCoverage.contract
Definition

The policy(s) which constitute this insurance coverage.

Control0..*
TypeReference(Contract)