Coverage | Medplum

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

Elements

Name Required Type Description
identifier Identifier[] Business Identifier for the coverage Details A unique identifier assigned to this coverage. 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.
status ✓ code active
type CodeableConcept Coverage category such as medical or accident Details The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.
policyHolder Reference< Patient RelatedPerson
subscriber Reference< Patient RelatedPerson >
subscriberId string ID assigned to the subscriber Details The insurer assigned ID for the Subscriber.
beneficiary ✓ Reference< Patient > Plan beneficiary Details The party who benefits from the insurance coverage; the patient when products and/or services are provided.
dependent string Dependent number Details A unique identifier for a dependent under the coverage. Periodically the member number is constructed from the subscriberId and the dependant number.
relationship CodeableConcept Beneficiary relationship to the subscriber Details The relationship of beneficiary (patient) to the subscriber. Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.
period Period Coverage start and end dates Details 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.
payor ✓ Reference< Organization Patient
class CoverageClass[] Additional coverage classifications Details A suite of underwriter specific classifiers. For example may be used to identify a class of coverage or employer group, Policy, Plan.
id string Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension Extension[] Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension Extension[] Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
type ✓ CodeableConcept Type of class such as 'group' or 'plan' Details The 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, Plan.
value ✓ string Value associated with the type Details The alphanumeric string value associated with the insurer issued label. For example, the Group or Plan number.
name string Human readable description of the type and value Details A short description for the class.
order positiveInt Relative order of the coverage Details 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.
network string Insurer network Details 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.
costToBeneficiary CoverageCostToBeneficiary[] Patient payments for services/products Details 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. For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.
id string Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension Extension[] Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension Extension[] Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
type ✓ CodeableConcept Exception category Details The code for the specific exception.
period Period The effective period of the exception Details The timeframe during when the exception is in force.
subrogation boolean Reimbursement to insurer Details When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs. Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.
contract Reference< Contract >[] Contract details Details The policy(s) which constitute this insurance coverage.

Search Parameters

Name Type Description Expression
beneficiary reference Covered party Coverage.beneficiary
class-type token Coverage class (eg. plan, group) Coverage.class.type
class-value string Value of the class (eg. Plan number, group number) Coverage.class.value
dependent string Dependent number Coverage.dependent
identifier token The primary identifier of the insured and the coverage Coverage.identifier
patient reference Retrieve coverages for a patient Coverage.beneficiary
payor reference The identity of the insurer or party paying for services Coverage.payor
policy-holder reference Reference to the policyholder Coverage.policyHolder
status token The status of the Coverage Coverage.status
subscriber reference Reference to the subscriber Coverage.subscriber
type token The kind of coverage (health plan, auto, Workers Compensation) Coverage.type

Inherited Elements

Name Required Type Description
id string Logical id of this artifact Details The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
meta Meta Metadata about the resource Details The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
implicitRules uri A set of rules under which this content was created Details A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
language code Language of the resource content Details The base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
text Narrative Text summary of the resource, for human interpretation Details A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied).
contained Resource[] Contained, inline Resources Details These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
extension Extension[] Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension Extension[] Extensions that cannot be ignored Details May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.