Coverage

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

Columns

Header row
# path type required description
0 resourceType string * Resource type identifier. Must be string "Coverage"
1 integer * Number of subrows
2 id string * Logical id of this artifact
3 status code active | cancelled | draft | entered-in-error
type CodeableConcept Coverage category such as medical or accident
type.coding Coding Code defined by a terminology system
4 type.coding.system uri Identity of the terminology system
5 type.coding.version string Version of the system - if relevant
6 type.coding.code code Symbol in syntax defined by the system
7 type.coding.display string Representation defined by the system
8 type.coding.userSelected boolean If this coding was chosen directly by the user
9 type.text string Plain text representation of the concept
policyHolder Reference Owner of the policy
10 policyHolder.reference string Literal reference, Relative, internal or absolute URL
11 policyHolder.type uri Type the reference refers to (e.g. "Patient")
policyHolder.identifier Identifier Logical reference, when literal reference is not known
12 policyHolder.identifier.use code usual | official | temp | secondary | old (If known)
policyHolder.identifier.type CodeableConcept Description of identifier
policyHolder.identifier.type.coding Coding Code defined by a terminology system
13 policyHolder.identifier.type.coding.system uri Identity of the terminology system
14 policyHolder.identifier.type.coding.version string Version of the system - if relevant
15 policyHolder.identifier.type.coding.code code Symbol in syntax defined by the system
16 policyHolder.identifier.type.coding.display string Representation defined by the system
17 policyHolder.identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
18 policyHolder.identifier.type.text string Plain text representation of the concept
19 policyHolder.identifier.system uri The namespace for the identifier value
20 policyHolder.identifier.value string The value that is unique
policyHolder.identifier.period Period Time period when id is/was valid for use
21 policyHolder.identifier.period.start dateTime Starting time with inclusive boundary
22 policyHolder.identifier.period.end dateTime End time with inclusive boundary, if not ongoing
23 policyHolder.display string Text alternative for the resource
subscriber Reference Subscriber to the policy
24 subscriber.reference string Literal reference, Relative, internal or absolute URL
25 subscriber.type uri Type the reference refers to (e.g. "Patient")
subscriber.identifier Identifier Logical reference, when literal reference is not known
26 subscriber.identifier.use code usual | official | temp | secondary | old (If known)
subscriber.identifier.type CodeableConcept Description of identifier
subscriber.identifier.type.coding Coding Code defined by a terminology system
27 subscriber.identifier.type.coding.system uri Identity of the terminology system
28 subscriber.identifier.type.coding.version string Version of the system - if relevant
29 subscriber.identifier.type.coding.code code Symbol in syntax defined by the system
30 subscriber.identifier.type.coding.display string Representation defined by the system
31 subscriber.identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
32 subscriber.identifier.type.text string Plain text representation of the concept
33 subscriber.identifier.system uri The namespace for the identifier value
34 subscriber.identifier.value string The value that is unique
subscriber.identifier.period Period Time period when id is/was valid for use
35 subscriber.identifier.period.start dateTime Starting time with inclusive boundary
36 subscriber.identifier.period.end dateTime End time with inclusive boundary, if not ongoing
37 subscriber.display string Text alternative for the resource
38 subscriberId string ID assigned to the subscriber
beneficiary Reference Plan beneficiary
39 beneficiary.reference string Literal reference, Relative, internal or absolute URL
40 beneficiary.type uri Type the reference refers to (e.g. "Patient")
beneficiary.identifier Identifier Logical reference, when literal reference is not known
41 beneficiary.identifier.use code usual | official | temp | secondary | old (If known)
beneficiary.identifier.type CodeableConcept Description of identifier
beneficiary.identifier.type.coding Coding Code defined by a terminology system
42 beneficiary.identifier.type.coding.system uri Identity of the terminology system
43 beneficiary.identifier.type.coding.version string Version of the system - if relevant
44 beneficiary.identifier.type.coding.code code Symbol in syntax defined by the system
45 beneficiary.identifier.type.coding.display string Representation defined by the system
46 beneficiary.identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
47 beneficiary.identifier.type.text string Plain text representation of the concept
48 beneficiary.identifier.system uri The namespace for the identifier value
49 beneficiary.identifier.value string The value that is unique
beneficiary.identifier.period Period Time period when id is/was valid for use
50 beneficiary.identifier.period.start dateTime Starting time with inclusive boundary
51 beneficiary.identifier.period.end dateTime End time with inclusive boundary, if not ongoing
52 beneficiary.display string Text alternative for the resource
53 dependent string Dependent number
relationship CodeableConcept Beneficiary relationship to the subscriber
relationship.coding Coding Code defined by a terminology system
54 relationship.coding.system uri Identity of the terminology system
55 relationship.coding.version string Version of the system - if relevant
56 relationship.coding.code code Symbol in syntax defined by the system
57 relationship.coding.display string Representation defined by the system
58 relationship.coding.userSelected boolean If this coding was chosen directly by the user
59 relationship.text string Plain text representation of the concept
period Period Coverage start and end dates
60 period.start dateTime Starting time with inclusive boundary
61 period.end dateTime End time with inclusive boundary, if not ongoing
62 order positiveInt Relative order of the coverage
63 network string Insurer network
64 subrogation boolean Reimbursement to insurer
Row identifier
# path type required description
0 string * Subrow identifier. Must be string "identifier"
identifier Identifier Business Identifier for the coverage
1 identifier.use code usual | official | temp | secondary | old (If known)
identifier.type CodeableConcept Description of identifier
identifier.type.coding Coding Code defined by a terminology system
2 identifier.type.coding.system uri Identity of the terminology system
3 identifier.type.coding.version string Version of the system - if relevant
4 identifier.type.coding.code code Symbol in syntax defined by the system
5 identifier.type.coding.display string Representation defined by the system
6 identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
7 identifier.type.text string Plain text representation of the concept
8 identifier.system uri The namespace for the identifier value
9 identifier.value string The value that is unique
identifier.period Period Time period when id is/was valid for use
10 identifier.period.start dateTime Starting time with inclusive boundary
11 identifier.period.end dateTime End time with inclusive boundary, if not ongoing
Row payor
# path type required description
0 string * Subrow identifier. Must be string "payor"
payor Reference Issuer of the policy
1 payor.reference string Literal reference, Relative, internal or absolute URL
2 payor.type uri Type the reference refers to (e.g. "Patient")
payor.identifier Identifier Logical reference, when literal reference is not known
3 payor.identifier.use code usual | official | temp | secondary | old (If known)
payor.identifier.type CodeableConcept Description of identifier
payor.identifier.type.coding Coding Code defined by a terminology system
4 payor.identifier.type.coding.system uri Identity of the terminology system
5 payor.identifier.type.coding.version string Version of the system - if relevant
6 payor.identifier.type.coding.code code Symbol in syntax defined by the system
7 payor.identifier.type.coding.display string Representation defined by the system
8 payor.identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
9 payor.identifier.type.text string Plain text representation of the concept
10 payor.identifier.system uri The namespace for the identifier value
11 payor.identifier.value string The value that is unique
payor.identifier.period Period Time period when id is/was valid for use
12 payor.identifier.period.start dateTime Starting time with inclusive boundary
13 payor.identifier.period.end dateTime End time with inclusive boundary, if not ongoing
14 payor.display string Text alternative for the resource
Row class
# path type required description
0 string * Subrow identifier. Must be string "class"
class Additional coverage classifications
class.type CodeableConcept Type of class such as 'group' or 'plan'
class.type.coding Coding Code defined by a terminology system
1 class.type.coding.system uri Identity of the terminology system
2 class.type.coding.version string Version of the system - if relevant
3 class.type.coding.code code Symbol in syntax defined by the system
4 class.type.coding.display string Representation defined by the system
5 class.type.coding.userSelected boolean If this coding was chosen directly by the user
6 class.type.text string Plain text representation of the concept
7 class.value string Value associated with the type
8 class.name string Human readable description of the type and value
Row costToBeneficiary
# path type required description
0 string * Subrow identifier. Must be string "costToBeneficiary"
costToBeneficiary Patient payments for services/products
costToBeneficiary.type CodeableConcept Cost category
costToBeneficiary.type.coding Coding Code defined by a terminology system
1 costToBeneficiary.type.coding.system uri Identity of the terminology system
2 costToBeneficiary.type.coding.version string Version of the system - if relevant
3 costToBeneficiary.type.coding.code code Symbol in syntax defined by the system
4 costToBeneficiary.type.coding.display string Representation defined by the system
5 costToBeneficiary.type.coding.userSelected boolean If this coding was chosen directly by the user
6 costToBeneficiary.type.text string Plain text representation of the concept
costToBeneficiary.value[x] The amount or percentage due from the beneficiary
costToBeneficiary.valueQuantity Quantity
7 costToBeneficiary.valueQuantity.value decimal Numerical value (with implicit precision)
8 costToBeneficiary.valueQuantity.unit string Unit representation
9 costToBeneficiary.valueQuantity.system uri System that defines coded unit form
10 costToBeneficiary.valueQuantity.code code Coded form of the unit
costToBeneficiary.valueMoney Money
11 costToBeneficiary.valueMoney.value decimal Numerical value (with implicit precision)
12 costToBeneficiary.valueMoney.currency code ISO 4217 Currency Code
costToBeneficiary.exception Exceptions for patient payments
costToBeneficiary.exception.type CodeableConcept Exception category
costToBeneficiary.exception.type.coding Coding Code defined by a terminology system
13 costToBeneficiary.exception.type.coding.system uri Identity of the terminology system
14 costToBeneficiary.exception.type.coding.version string Version of the system - if relevant
15 costToBeneficiary.exception.type.coding.code code Symbol in syntax defined by the system
16 costToBeneficiary.exception.type.coding.display string Representation defined by the system
17 costToBeneficiary.exception.type.coding.userSelected boolean If this coding was chosen directly by the user
18 costToBeneficiary.exception.type.text string Plain text representation of the concept
costToBeneficiary.exception.period Period The effective period of the exception
19 costToBeneficiary.exception.period.start dateTime Starting time with inclusive boundary
20 costToBeneficiary.exception.period.end dateTime End time with inclusive boundary, if not ongoing
Row contract
# path type required description
0 string * Subrow identifier. Must be string "contract"
contract Reference Contract details
1 contract.reference string Literal reference, Relative, internal or absolute URL
2 contract.type uri Type the reference refers to (e.g. "Patient")
contract.identifier Identifier Logical reference, when literal reference is not known
3 contract.identifier.use code usual | official | temp | secondary | old (If known)
contract.identifier.type CodeableConcept Description of identifier
contract.identifier.type.coding Coding Code defined by a terminology system
4 contract.identifier.type.coding.system uri Identity of the terminology system
5 contract.identifier.type.coding.version string Version of the system - if relevant
6 contract.identifier.type.coding.code code Symbol in syntax defined by the system
7 contract.identifier.type.coding.display string Representation defined by the system
8 contract.identifier.type.coding.userSelected boolean If this coding was chosen directly by the user
9 contract.identifier.type.text string Plain text representation of the concept
10 contract.identifier.system uri The namespace for the identifier value
11 contract.identifier.value string The value that is unique
contract.identifier.period Period Time period when id is/was valid for use
12 contract.identifier.period.start dateTime Starting time with inclusive boundary
13 contract.identifier.period.end dateTime End time with inclusive boundary, if not ongoing
14 contract.display string Text alternative for the resource

Examples

Example #1
Input CSV
Coverage,7,"7546D","active","http://terminology.hl7.org/CodeSystem/v3-ActCode",,"EHCPOL","extended healthcare",,,,,,,,,,,,,,,,,"Patient/5",,,,,,,,,,,,,,"AB9876","Patient/5",,,,,,,,,,,,,,"1",,,"self",,,,"2011-03-17","2012-03-17",2,"5",
identifier,,,,,,,,"http://xyz.com/codes/identifier","AB98761",,
payor,"Organization/2",,,,,,,,,,,,,
class,"http://terminology.hl7.org/CodeSystem/coverage-class",,"group",,,,"WESTAIR","Western Airlines"
class,"http://terminology.hl7.org/CodeSystem/coverage-class",,"plan",,,,"BG4352","Full Coverage: Medical, Dental, Pharmacy, Vision, EHC"
class,"http://terminology.hl7.org/CodeSystem/coverage-class",,"subplan",,,,"D15C9","Platinum"
costToBeneficiary,"http://terminology.hl7.org/CodeSystem/coverage-copay-type",,"gpvisit",,,,,,,,20,"USD","http://terminology.hl7.org/CodeSystem/ex-coverage-financial-exception",,"retired",,,,"2018-01-01","2018-12-31"
contract,"Contract/INS-101",,,,,,,,,,,,,
Resulting resource
{
  "resourceType": "Coverage",
  "id": "7546D",
  "identifier": [
    {
      "system": "http://xyz.com/codes/identifier",
      "value": "AB98761"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code": "EHCPOL",
        "display": "extended healthcare"
      }
    ]
  },
  "subscriber": {
    "reference": "Patient/5"
  },
  "subscriberId": "AB9876",
  "beneficiary": {
    "reference": "Patient/5"
  },
  "dependent": "1",
  "relationship": {
    "coding": [
      {
        "code": "self"
      }
    ]
  },
  "period": {
    "start": "2011-03-17",
    "end": "2012-03-17"
  },
  "payor": [
    {
      "reference": "Organization/2"
    }
  ],
  "class": [
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "group"
          }
        ]
      },
      "value": "WESTAIR",
      "name": "Western Airlines"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "plan"
          }
        ]
      },
      "value": "BG4352",
      "name": "Full Coverage: Medical, Dental, Pharmacy, Vision, EHC"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "subplan"
          }
        ]
      },
      "value": "D15C9",
      "name": "Platinum"
    }
  ],
  "order": 2,
  "network": "5",
  "costToBeneficiary": [
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
            "code": "gpvisit"
          }
        ]
      },
      "valueMoney": {
        "value": 20,
        "currency": "USD"
      },
      "exception": [
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/ex-coverage-financial-exception",
                "code": "retired"
              }
            ]
          },
          "period": {
            "start": "2018-01-01",
            "end": "2018-12-31"
          }
        }
      ]
    }
  ],
  "contract": [
    {
      "reference": "Contract/INS-101"
    }
  ]
}
Example #2
Input CSV
Coverage,2,"7547E","active","http://terminology.hl7.org/CodeSystem/v3-ActCode",,"EHCPOL","extended healthcare",,,,,,,,,,,,,,,,,"Patient/5",,,,,,,,,,,,,,,"Patient/5",,,,,,,,,,,,,,,,,"self",,,,,"2012-03-17",,,
identifier,,,,,,,,"http://ehic.com/insurer/123456789/member","A123456780",,
payor,,,,,,,,,,"http://ehic.com/insurer","123456789",,,
Resulting resource
{
  "resourceType": "Coverage",
  "id": "7547E",
  "identifier": [
    {
      "system": "http://ehic.com/insurer/123456789/member",
      "value": "A123456780"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code": "EHCPOL",
        "display": "extended healthcare"
      }
    ]
  },
  "subscriber": {
    "reference": "Patient/5"
  },
  "beneficiary": {
    "reference": "Patient/5"
  },
  "relationship": {
    "coding": [
      {
        "code": "self"
      }
    ]
  },
  "period": {
    "end": "2012-03-17"
  },
  "payor": [
    {
      "identifier": {
        "system": "http://ehic.com/insurer",
        "value": "123456789"
      }
    }
  ]
}
Example #3
Input CSV
Coverage,14,"9876B1","active","http://terminology.hl7.org/CodeSystem/v3-ActCode",,"EHCPOL","extended healthcare",,,"http://benefitsinc.com/FHIR/Organization/CBI35",,,,,,,,,,,,,,"Patient/4",,,,,,,,,,,,,,,"Patient/4",,,,,,,,,,,,,,"0",,,"self",,,,"2011-05-23","2012-05-23",,,
identifier,,,,,,,,"http://benefitsinc.com/certificate","12345",,
payor,"Organization/2",,,,,,,,,,,,,
class,"http://terminology.hl7.org/CodeSystem/coverage-class",,"group",,,,"CB135","Corporate Baker's Inc. Local #35"
class,"http://terminology.hl7.org/CodeSystem/coverage-class",,"subgroup",,,,"123","Trainee Part-time Benefits"
class,"http://terminology.hl7.org/CodeSystem/coverage-class",,"plan",,,,"B37FC","Full Coverage: Medical, Dental, Pharmacy, Vision, EHC"
class,"http://terminology.hl7.org/CodeSystem/coverage-class",,"subplan",,,,"P7","Includes afterlife benefits"
class,"http://terminology.hl7.org/CodeSystem/coverage-class",,"class",,,,"SILVER","Silver: Family Plan spouse only"
class,"http://terminology.hl7.org/CodeSystem/coverage-class",,"subclass",,,,"Tier2","Low deductable, max $20 copay"
class,"http://terminology.hl7.org/CodeSystem/coverage-class",,"sequence",,,,"9",
class,"http://terminology.hl7.org/CodeSystem/coverage-class",,"rxid",,,,"MDF12345",
class,"http://terminology.hl7.org/CodeSystem/coverage-class",,"rxbin",,,,"987654",
class,"http://terminology.hl7.org/CodeSystem/coverage-class",,"rxgroup",,,,"M35PT",
class,"http://terminology.hl7.org/CodeSystem/coverage-class",,"rxpcn",,,,"234516",
class,"http://terminology.hl7.org/CodeSystem/coverage-class",,"sequence",,,,"9",
Resulting resource
{
  "resourceType": "Coverage",
  "id": "9876B1",
  "identifier": [
    {
      "system": "http://benefitsinc.com/certificate",
      "value": "12345"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code": "EHCPOL",
        "display": "extended healthcare"
      }
    ]
  },
  "policyHolder": {
    "reference": "http://benefitsinc.com/FHIR/Organization/CBI35"
  },
  "subscriber": {
    "reference": "Patient/4"
  },
  "beneficiary": {
    "reference": "Patient/4"
  },
  "dependent": "0",
  "relationship": {
    "coding": [
      {
        "code": "self"
      }
    ]
  },
  "period": {
    "start": "2011-05-23",
    "end": "2012-05-23"
  },
  "payor": [
    {
      "reference": "Organization/2"
    }
  ],
  "class": [
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "group"
          }
        ]
      },
      "value": "CB135",
      "name": "Corporate Baker's Inc. Local #35"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "subgroup"
          }
        ]
      },
      "value": "123",
      "name": "Trainee Part-time Benefits"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "plan"
          }
        ]
      },
      "value": "B37FC",
      "name": "Full Coverage: Medical, Dental, Pharmacy, Vision, EHC"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "subplan"
          }
        ]
      },
      "value": "P7",
      "name": "Includes afterlife benefits"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "class"
          }
        ]
      },
      "value": "SILVER",
      "name": "Silver: Family Plan spouse only"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "subclass"
          }
        ]
      },
      "value": "Tier2",
      "name": "Low deductable, max $20 copay"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "sequence"
          }
        ]
      },
      "value": "9"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "rxid"
          }
        ]
      },
      "value": "MDF12345"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "rxbin"
          }
        ]
      },
      "value": "987654"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "rxgroup"
          }
        ]
      },
      "value": "M35PT"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "rxpcn"
          }
        ]
      },
      "value": "234516"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "sequence"
          }
        ]
      },
      "value": "9"
    }
  ]
}
Example #4
Input CSV
Coverage,2,"SP1234","active","http://terminology.hl7.org/CodeSystem/coverage-selfpay",,"pay","PAY",,,,,,,,,,,,,,,,,"Patient/5",,,,,,,,,,,,,,,"Patient/5",,,,,,,,,,,,,,,,,"self",,,,,"2012-03-17",,,
identifier,,,,,,,,"http://hospitalx.com/selfpayagreement","SP12345678",,
payor,"Patient/5",,,,,,,,,,,,,
Resulting resource
{
  "resourceType": "Coverage",
  "id": "SP1234",
  "identifier": [
    {
      "system": "http://hospitalx.com/selfpayagreement",
      "value": "SP12345678"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/coverage-selfpay",
        "code": "pay",
        "display": "PAY"
      }
    ]
  },
  "subscriber": {
    "reference": "Patient/5"
  },
  "beneficiary": {
    "reference": "Patient/5"
  },
  "relationship": {
    "coding": [
      {
        "code": "self"
      }
    ]
  },
  "period": {
    "end": "2012-03-17"
  },
  "payor": [
    {
      "reference": "Patient/5"
    }
  ]
}