DSTU2

This page is part of the FHIR Specification (v1.0.2: DSTU 2). 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

7.3 Resource Coverage - Content

Financial Management

Work Group

Maturity Level: 0

Compartments: Not linked to any defined compartments

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

7.3.1 Scope and Usage

The Coverage resource is intended to provide the high level identifiers and potentially descriptors of insurance plans which may used to pay for, in part or in whole, the provision of health care products and services. Todo

This resource is referenced by Claim, ClaimResponse and EnrollmentRequest

Structure

Name	Flags	Card.	Type	Description & Constraints
Coverage			DomainResource	Insurance or medical plan
issuer	Σ	0..1	Reference(Organization)	An identifier for the plan issuer
bin		0..1	Identifier	BIN Number
period	Σ	0..1	Period	Coverage start and end dates
type	Σ	0..1	Coding	Type of coverage ActCoverageTypeCode (Example)
subscriberId	Σ	0..1	Identifier	Subscriber ID
identifier	Σ	0..*	Identifier	The primary coverage ID
group	Σ	0..1	string	An identifier for the group
plan	Σ	0..1	string	An identifier for the plan
subPlan	Σ	0..1	string	An identifier for the subsection of the plan
dependent	Σ	0..1	positiveInt	The dependent number
sequence	Σ	0..1	positiveInt	The plan instance or sequence counter
subscriber	?!	0..1	Reference(Patient)	Plan holder information
network	Σ	0..1	Identifier	Insurer network
contract		0..*	Reference(Contract)	Contract details
Documentation for this format

UML Diagram

XML Template

<Coverage xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <issuer><!-- 0..1 Reference(Organization) An identifier for the plan issuer --></issuer>
 <bin><!-- 0..1 Identifier BIN Number --></bin>
 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <type><!-- 0..1 Coding Type of coverage --></type>
 <subscriberId><!-- 0..1 Identifier Subscriber ID --></subscriberId>
 <identifier><!-- 0..* Identifier The primary coverage ID --></identifier>
 <group value="[string]"/><!-- 0..1 An identifier for the group -->
 <plan value="[string]"/><!-- 0..1 An identifier for the plan -->
 <subPlan value="[string]"/><!-- 0..1 An identifier for the subsection of the plan -->
 <dependent value="[positiveInt]"/><!-- 0..1 The dependent number -->
 <sequence value="[positiveInt]"/><!-- 0..1 The plan instance or sequence counter -->
 <subscriber><!-- 0..1 Reference(Patient) Plan holder information --></subscriber>
 <network><!-- 0..1 Identifier Insurer network --></network>
 <contract><!-- 0..* Reference(Contract) Contract details --></contract>
</Coverage>

JSON Template

{
  "resourceType" : "Coverage",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "issuer" : { Reference(Organization) }, // An identifier for the plan issuer
  "bin" : { Identifier }, // BIN Number
  "period" : { Period }, // Coverage start and end dates
  "type" : { Coding }, // Type of coverage
  "subscriberId" : { Identifier }, // Subscriber ID
  "identifier" : [{ Identifier }], // The primary coverage ID
  "group" : "<string>", // An identifier for the group
  "plan" : "<string>", // An identifier for the plan
  "subPlan" : "<string>", // An identifier for the subsection of the plan
  "dependent" : "<positiveInt>", // The dependent number
  "sequence" : "<positiveInt>", // The plan instance or sequence counter
  "subscriber" : { Reference(Patient) }, // Plan holder information
  "network" : { Identifier }, // Insurer network
  "contract" : [{ Reference(Contract) }] // Contract details
}

Structure

Name	Flags	Card.	Type	Description & Constraints
Coverage			DomainResource	Insurance or medical plan
issuer	Σ	0..1	Reference(Organization)	An identifier for the plan issuer
bin		0..1	Identifier	BIN Number
period	Σ	0..1	Period	Coverage start and end dates
type	Σ	0..1	Coding	Type of coverage ActCoverageTypeCode (Example)
subscriberId	Σ	0..1	Identifier	Subscriber ID
identifier	Σ	0..*	Identifier	The primary coverage ID
group	Σ	0..1	string	An identifier for the group
plan	Σ	0..1	string	An identifier for the plan
subPlan	Σ	0..1	string	An identifier for the subsection of the plan
dependent	Σ	0..1	positiveInt	The dependent number
sequence	Σ	0..1	positiveInt	The plan instance or sequence counter
subscriber	?!	0..1	Reference(Patient)	Plan holder information
network	Σ	0..1	Identifier	Insurer network
contract		0..*	Reference(Contract)	Contract details
Documentation for this format

UML Diagram

XML Template

<Coverage xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <issuer><!-- 0..1 Reference(Organization) An identifier for the plan issuer --></issuer>
 <bin><!-- 0..1 Identifier BIN Number --></bin>
 <period><!-- 0..1 Period Coverage start and end dates --></period>
 <type><!-- 0..1 Coding Type of coverage --></type>
 <subscriberId><!-- 0..1 Identifier Subscriber ID --></subscriberId>
 <identifier><!-- 0..* Identifier The primary coverage ID --></identifier>
 <group value="[string]"/><!-- 0..1 An identifier for the group -->
 <plan value="[string]"/><!-- 0..1 An identifier for the plan -->
 <subPlan value="[string]"/><!-- 0..1 An identifier for the subsection of the plan -->
 <dependent value="[positiveInt]"/><!-- 0..1 The dependent number -->
 <sequence value="[positiveInt]"/><!-- 0..1 The plan instance or sequence counter -->
 <subscriber><!-- 0..1 Reference(Patient) Plan holder information --></subscriber>
 <network><!-- 0..1 Identifier Insurer network --></network>
 <contract><!-- 0..* Reference(Contract) Contract details --></contract>
</Coverage>

JSON Template

{
  "resourceType" : "Coverage",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "issuer" : { Reference(Organization) }, // An identifier for the plan issuer
  "bin" : { Identifier }, // BIN Number
  "period" : { Period }, // Coverage start and end dates
  "type" : { Coding }, // Type of coverage
  "subscriberId" : { Identifier }, // Subscriber ID
  "identifier" : [{ Identifier }], // The primary coverage ID
  "group" : "<string>", // An identifier for the group
  "plan" : "<string>", // An identifier for the plan
  "subPlan" : "<string>", // An identifier for the subsection of the plan
  "dependent" : "<positiveInt>", // The dependent number
  "sequence" : "<positiveInt>", // The plan instance or sequence counter
  "subscriber" : { Reference(Patient) }, // Plan holder information
  "network" : { Identifier }, // Insurer network
  "contract" : [{ Reference(Contract) }] // Contract details
}

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

7.3.2.1 Terminology Bindings

Path	Definition	Type	Reference
Coverage.type	The type of insurance: public health, worker compensation; private accident, auto, private health, etc.).	Example	ActCoverageTypeCode

Path

Definition

Type

Reference

Coverage.type

The type of insurance: public health, worker compensation; private accident, auto, private health, etc.).

Example

ActCoverageTypeCode

7.3.3 Search Parameters

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

Name	Type	Description	Paths
dependent	token	Dependent number	Coverage.dependent
group	token	Group identifier	Coverage.group
identifier	token	The primary identifier of the insured	Coverage.identifier
issuer	reference	The identity of the insurer	Coverage.issuer (Organization)
plan	token	A plan or policy identifier	Coverage.plan
sequence	token	Sequence number	Coverage.sequence
subplan	token	Sub-plan identifier	Coverage.subPlan
type	token	The kind of coverage	Coverage.type