Release 4

This page is part of the FHIR Specification (v4.0.1: R4 - Mixed Normative and STU) in it's permanent home (it will always be available at this URL). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

13.1 Resource Coverage - Content

Financial Management Work GroupMaturity Level: 2 Trial UseSecurity 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.

13.1.1 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.

13.1.2 Boundaries and Relationships

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, CoverageEligibilityRequest, CoverageEligibilityResponse, DeviceRequest, EnrollmentRequest, ExplanationOfBenefit, MedicationRequest, ServiceRequest and Task

13.1.3 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage TUDomainResourceInsurance or medical plan or a payment agreement
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ0..*IdentifierBusiness Identifier for the coverage
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... type Σ0..1CodeableConceptCoverage category such as medical or accident
Coverage Type and Self-Pay Codes (Preferred)
... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId Σ0..1stringID assigned to the subscriber
... beneficiary Σ1..1Reference(Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
SubscriberPolicyholder Relationship Codes (Extensible)
... period Σ0..1PeriodCoverage start and end dates
... payor Σ1..*Reference(Organization | Patient | RelatedPerson)Issuer of the policy
... class 0..*BackboneElementAdditional coverage classifications
.... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Coverage Class Codes (Extensible)
.... value Σ1..1stringValue associated with the type
.... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... type Σ0..1CodeableConceptCost category
Coverage Copay Type Codes (Extensible)
.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantitySimpleQuantity
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... type Σ1..1CodeableConceptException category
Example Coverage Financial Exception Codes (Example)
..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

UML Diagram (Legend)

Coverage (DomainResource)A unique identifier assigned to this coverageidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required)FinancialResourceStatusCodes! »The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organizationtype : 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)CoverageTypeAndSelf-PayCodes? »The party who 'owns' the insurance policypolicyHolder : 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 duesubscriber : Reference [0..1] « Patient|RelatedPerson »The insurer assigned ID for the SubscribersubscriberId : string [0..1]The party who benefits from the insurance coverage; the patient when products and/or services are providedbeneficiary : Reference [1..1] « Patient »A unique identifier for a dependent under the coveragedependent : string [0..1]The relationship of beneficiary (patient) to the subscriberrelationship : CodeableConcept [0..1] « The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). (Strength=Extensible)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 forceperiod : Period [0..1]The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreementspayor : Reference [1..*] « Organization|Patient|RelatedPerson »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 careorder : 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 applynetwork : string [0..1]When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costssubrogation : boolean [0..1]The policy(s) which constitute this insurance coveragecontract : Reference [0..*] « Contract »ClassThe type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plantype : CodeableConcept [1..1] « The policy classifications, eg. Group, Plan, Class, etc. (Strength=Extensible)CoverageClassCodes+ »The alphanumeric string value associated with the insurer issued labelvalue : string [1..1]A short description for the classname : string [0..1]CostToBeneficiaryThe category of patient centric costs associated with treatmenttype : CodeableConcept [0..1] « The types of services to which patient copayments are specified. (Strength=Extensible)CoverageCopayTypeCodes+ »The amount due from the patient for the cost categoryvalue[x] : Type [1..1] « Quantity(SimpleQuantity)|Money »ExemptionThe code for the specific exceptiontype : CodeableConcept [1..1] « The types of exceptions from the part or full value of financial obligations such as copays. (Strength=Example)ExampleCoverageFinancialExcep...?? »The timeframe during when the exception is in forceperiod : Period [0..1]A suite of underwriter specific classifiersclass[0..*]A suite of codes indicating exceptions or reductions to patient costs and their effective periodsexception[0..*]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 cardcostToBeneficiary[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><!-- 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(Patient|RelatedPerson|Organization) Owner of the policy --></policyHolder>
 <subscriber><!-- 0..1 Reference(Patient|RelatedPerson) Subscriber to the policy --></subscriber>
 <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" : "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(Patient|RelatedPerson|Organization) }, // 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: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: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(Patient|RelatedPerson|Organization) ]; # 0..1 Owner of the policy
  fhir:Coverage.subscriber [ Reference(Patient|RelatedPerson) ]; # 0..1 Subscriber to the policy
  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: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 R3

Coverage
Coverage.status
  • Min Cardinality changed from 0 to 1
  • Change value set from http://hl7.org/fhir/ValueSet/fm-status to http://hl7.org/fhir/ValueSet/fm-status|4.0.1
Coverage.beneficiary
  • Min Cardinality changed from 0 to 1
Coverage.relationship
  • Add Binding http://hl7.org/fhir/ValueSet/subscriber-relationship (extensible)
Coverage.payor
  • Min Cardinality changed from 0 to 1
Coverage.class
  • Renamed from grouping to class
  • Max Cardinality changed from 1 to *
Coverage.class.type
  • Added Mandatory Element
Coverage.class.value
  • Added Mandatory Element
Coverage.class.name
  • Added Element
Coverage.costToBeneficiary
  • Added Element
Coverage.costToBeneficiary.type
  • Added Element
Coverage.costToBeneficiary.value[x]
  • Added Mandatory Element
Coverage.costToBeneficiary.exception
  • Added Element
Coverage.costToBeneficiary.exception.type
  • Added Mandatory Element
Coverage.costToBeneficiary.exception.period
  • Added Element
Coverage.subrogation
  • Added Element
Coverage.grouping.group
  • deleted
Coverage.grouping.groupDisplay
  • deleted
Coverage.grouping.subGroup
  • deleted
Coverage.grouping.subGroupDisplay
  • deleted
Coverage.grouping.plan
  • deleted
Coverage.grouping.planDisplay
  • deleted
Coverage.grouping.subPlan
  • deleted
Coverage.grouping.subPlanDisplay
  • deleted
Coverage.grouping.class
  • deleted
Coverage.grouping.classDisplay
  • deleted
Coverage.grouping.subClass
  • deleted
Coverage.grouping.subClassDisplay
  • deleted
Coverage.sequence
  • deleted

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage TUDomainResourceInsurance or medical plan or a payment agreement
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ0..*IdentifierBusiness Identifier for the coverage
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... type Σ0..1CodeableConceptCoverage category such as medical or accident
Coverage Type and Self-Pay Codes (Preferred)
... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId Σ0..1stringID assigned to the subscriber
... beneficiary Σ1..1Reference(Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
SubscriberPolicyholder Relationship Codes (Extensible)
... period Σ0..1PeriodCoverage start and end dates
... payor Σ1..*Reference(Organization | Patient | RelatedPerson)Issuer of the policy
... class 0..*BackboneElementAdditional coverage classifications
.... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Coverage Class Codes (Extensible)
.... value Σ1..1stringValue associated with the type
.... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... type Σ0..1CodeableConceptCost category
Coverage Copay Type Codes (Extensible)
.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantitySimpleQuantity
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... type Σ1..1CodeableConceptException category
Example Coverage Financial Exception Codes (Example)
..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

UML Diagram (Legend)

Coverage (DomainResource)A unique identifier assigned to this coverageidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required)FinancialResourceStatusCodes! »The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organizationtype : 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)CoverageTypeAndSelf-PayCodes? »The party who 'owns' the insurance policypolicyHolder : 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 duesubscriber : Reference [0..1] « Patient|RelatedPerson »The insurer assigned ID for the SubscribersubscriberId : string [0..1]The party who benefits from the insurance coverage; the patient when products and/or services are providedbeneficiary : Reference [1..1] « Patient »A unique identifier for a dependent under the coveragedependent : string [0..1]The relationship of beneficiary (patient) to the subscriberrelationship : CodeableConcept [0..1] « The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). (Strength=Extensible)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 forceperiod : Period [0..1]The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreementspayor : Reference [1..*] « Organization|Patient|RelatedPerson »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 careorder : 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 applynetwork : string [0..1]When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costssubrogation : boolean [0..1]The policy(s) which constitute this insurance coveragecontract : Reference [0..*] « Contract »ClassThe type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plantype : CodeableConcept [1..1] « The policy classifications, eg. Group, Plan, Class, etc. (Strength=Extensible)CoverageClassCodes+ »The alphanumeric string value associated with the insurer issued labelvalue : string [1..1]A short description for the classname : string [0..1]CostToBeneficiaryThe category of patient centric costs associated with treatmenttype : CodeableConcept [0..1] « The types of services to which patient copayments are specified. (Strength=Extensible)CoverageCopayTypeCodes+ »The amount due from the patient for the cost categoryvalue[x] : Type [1..1] « Quantity(SimpleQuantity)|Money »ExemptionThe code for the specific exceptiontype : CodeableConcept [1..1] « The types of exceptions from the part or full value of financial obligations such as copays. (Strength=Example)ExampleCoverageFinancialExcep...?? »The timeframe during when the exception is in forceperiod : Period [0..1]A suite of underwriter specific classifiersclass[0..*]A suite of codes indicating exceptions or reductions to patient costs and their effective periodsexception[0..*]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 cardcostToBeneficiary[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><!-- 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(Patient|RelatedPerson|Organization) Owner of the policy --></policyHolder>
 <subscriber><!-- 0..1 Reference(Patient|RelatedPerson) Subscriber to the policy --></subscriber>
 <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" : "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(Patient|RelatedPerson|Organization) }, // 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: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: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(Patient|RelatedPerson|Organization) ]; # 0..1 Owner of the policy
  fhir:Coverage.subscriber [ Reference(Patient|RelatedPerson) ]; # 0..1 Subscriber to the policy
  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: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 Release 3

Coverage
Coverage.status
  • Min Cardinality changed from 0 to 1
  • Change value set from http://hl7.org/fhir/ValueSet/fm-status to http://hl7.org/fhir/ValueSet/fm-status|4.0.1
Coverage.beneficiary
  • Min Cardinality changed from 0 to 1
Coverage.relationship
  • Add Binding http://hl7.org/fhir/ValueSet/subscriber-relationship (extensible)
Coverage.payor
  • Min Cardinality changed from 0 to 1
Coverage.class
  • Renamed from grouping to class
  • Max Cardinality changed from 1 to *
Coverage.class.type
  • Added Mandatory Element
Coverage.class.value
  • Added Mandatory Element
Coverage.class.name
  • Added Element
Coverage.costToBeneficiary
  • Added Element
Coverage.costToBeneficiary.type
  • Added Element
Coverage.costToBeneficiary.value[x]
  • Added Mandatory Element
Coverage.costToBeneficiary.exception
  • Added Element
Coverage.costToBeneficiary.exception.type
  • Added Mandatory Element
Coverage.costToBeneficiary.exception.period
  • Added Element
Coverage.subrogation
  • Added Element
Coverage.grouping.group
  • deleted
Coverage.grouping.groupDisplay
  • deleted
Coverage.grouping.subGroup
  • deleted
Coverage.grouping.subGroupDisplay
  • deleted
Coverage.grouping.plan
  • deleted
Coverage.grouping.planDisplay
  • deleted
Coverage.grouping.subPlan
  • deleted
Coverage.grouping.subPlanDisplay
  • deleted
Coverage.grouping.class
  • deleted
Coverage.grouping.classDisplay
  • deleted
Coverage.grouping.subClass
  • deleted
Coverage.grouping.subClassDisplay
  • deleted
Coverage.sequence
  • deleted

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.)

 

See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions & the dependency analysis

13.1.3.1 Terminology Bindings

PathDefinitionTypeReference
Coverage.status A code specifying the state of the resource instance.RequiredFinancialResourceStatusCodes
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.PreferredCoverageTypeAndSelf-PayCodes
Coverage.relationship The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).ExtensibleSubscriberRelationshipCodes
Coverage.class.type The policy classifications, eg. Group, Plan, Class, etc.ExtensibleCoverageClassCodes
Coverage.costToBeneficiary.type The types of services to which patient copayments are specified.ExtensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.type The types of exceptions from the part or full value of financial obligations such as copays.ExampleExampleCoverageFinancialExceptionCodes

13.1.4 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionExpressionIn Common
beneficiaryreferenceCovered partyCoverage.beneficiary
(Patient)
class-typetokenCoverage class (eg. plan, group)Coverage.class.type
class-valuestringValue of the class (eg. Plan number, group number)Coverage.class.value
dependentstringDependent numberCoverage.dependent
identifiertokenThe primary identifier of the insured and the coverageCoverage.identifier
patientreferenceRetrieve coverages for a patientCoverage.beneficiary
(Patient)
payorreferenceThe identity of the insurer or party paying for servicesCoverage.payor
(Organization, Patient, RelatedPerson)
policy-holderreferenceReference to the policyholderCoverage.policyHolder
(Organization, Patient, RelatedPerson)
statustokenThe status of the CoverageCoverage.status
subscriberreferenceReference to the subscriberCoverage.subscriber
(Patient, RelatedPerson)
typetokenThe kind of coverage (health plan, auto, Workers Compensation)Coverage.type