{
"description": "Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.",
"_filename": "Coverage.json",
"package_name": "hl7.fhir.r4.id.core",
"date": "2019-11-01T09:29:23+11:00",
"derivation": "specialization",
"meta": {
"lastUpdated": "2021-12-31T09:38:38.421+00:00"
},
"publisher": "Health Level Seven International (Financial Management)",
"fhirVersion": "4.0.1",
"purpose": "Coverage provides a link between covered parties (patients) and the payors of their healthcare costs (both insurance and self-pay).",
"name": "Coverage",
"mapping": [ {
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Pattern",
"identity": "workflow"
}, {
"uri": "http://hl7.org/v3",
"name": "RIM Mapping",
"identity": "rim"
}, {
"uri": "http://hl7.org/fhir/fivews",
"name": "FiveWs Pattern Mapping",
"identity": "w5"
}, {
"uri": "http://www.cda-adc.ca/en/services/cdanet/",
"name": "Canadian Dental Association eclaims standard",
"identity": "cdanetv4"
}, {
"uri": "http://hl7.org/v2",
"name": "HL7 v2 Mapping",
"identity": "v2"
}, {
"uri": "http://www.pharmacists.ca/",
"name": "Canadian Pharmacy Associaiton eclaims standard",
"identity": "cpha3pharm"
} ],
"abstract": false,
"type": "Coverage",
"experimental": null,
"resourceType": "StructureDefinition",
"title": null,
"package_version": "0.1.0",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-category",
"valueString": "Financial.Support"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
"valueCode": "trial-use"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 2
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-security-category",
"valueCode": "patient"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "fm"
} ],
"status": "draft",
"id": "1afb640f-d3e5-43f1-ac41-e78320d27bff",
"kind": "resource",
"url": "https://fhir.kemkes.go.id/r4/StructureDefinition/Coverage",
"version": "4.0.1",
"differential": {
"element": [ {
"id": "Coverage",
"path": "Coverage",
"short": "Insurance or medical plan or a payment agreement",
"comment": "The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.",
"mapping": [ {
"map": "Event",
"identity": "workflow"
}, {
"map": "Coverage",
"identity": "rim"
} ],
"definition": "Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment."
}, {
"path": "Coverage.identifier",
"requirements": "Allows coverages to be distinguished and referenced.",
"definition": "A unique identifier assigned to this coverage.",
"short": "Business Identifier for the coverage",
"mapping": [ {
"map": "Event.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
}, {
"map": "C02",
"identity": "cdanetv4"
}, {
"map": "IN1-2",
"identity": "v2"
}, {
"map": ".id",
"identity": "rim"
}, {
"map": "C.32, C.33, C.39",
"identity": "cpha3pharm"
} ],
"type": [ {
"code": "Identifier"
} ],
"id": "Coverage.identifier",
"comment": "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.",
"isSummary": true
}, {
"path": "Coverage.status",
"requirements": "Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.",
"min": 1,
"definition": "The status of the resource instance.",
"isModifier": true,
"short": "active | cancelled | draft | entered-in-error",
"mapping": [ {
"map": "Event.status",
"identity": "workflow"
}, {
"map": "FiveWs.status",
"identity": "w5"
}, {
"map": "Act.status",
"identity": "rim"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/fm-status|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CoverageStatus"
} ],
"description": "A code specifying the state of the resource instance."
},
"max": "1",
"id": "Coverage.status",
"comment": "This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.",
"isModifierReason": "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",
"isSummary": true
}, {
"path": "Coverage.type",
"requirements": "The order of application of coverages is dependent on the types of coverage.",
"definition": "The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.",
"short": "Coverage category such as medical or accident",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": "IN1-15",
"identity": "v2"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/coverage-type",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CoverageType"
} ],
"description": "The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization."
},
"max": "1",
"id": "Coverage.type",
"isSummary": true
}, {
"path": "Coverage.policyHolder",
"requirements": "This provides employer information in the case of Worker's Compensation and other policies.",
"definition": "The party who 'owns' the insurance policy.",
"short": "Owner of the policy",
"mapping": [ {
"map": "FiveWs.subject[x]",
"identity": "w5"
}, {
"map": "D01 through D09",
"identity": "cdanetv4"
}, {
"map": "IN1-16, 18, 19-name of insured, address, date of birth",
"identity": "v2"
}, {
"map": "C.35",
"identity": "cpha3pharm"
}, {
"map": "FiveWs.subject",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "1",
"id": "Coverage.policyHolder",
"comment": "For example: may be an individual, corporation or the subscriber's employer.",
"isSummary": true
}, {
"path": "Coverage.subscriber",
"requirements": "This is the party who is entitled to the benfits under the policy.",
"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.",
"short": "Subscriber to the policy",
"mapping": [ {
"map": "FiveWs.subject[x]",
"identity": "w5"
}, {
"map": "D01 through D09",
"identity": "cdanetv4"
}, {
"map": "IN1-16, 18, 19-name of insured, address, date of birth",
"identity": "v2"
}, {
"map": "C.35",
"identity": "cpha3pharm"
}, {
"map": "FiveWs.subject",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson" ]
} ],
"max": "1",
"id": "Coverage.subscriber",
"comment": "May be self or a parent in the case of dependants.",
"isSummary": true
}, {
"path": "Coverage.subscriberId",
"requirements": "The insurer requires this identifier on correspondance and claims (digital and otherwise).",
"definition": "The insurer assigned ID for the Subscriber.",
"short": "ID assigned to the subscriber",
"mapping": [ {
"map": "FiveWs.subject[x]",
"identity": "w5"
}, {
"map": "D01 through D09",
"identity": "cdanetv4"
}, {
"map": "IN1-16, 18, 19-name of insured, address, date of birth",
"identity": "v2"
}, {
"map": "C.35",
"identity": "cpha3pharm"
}, {
"map": "FiveWs.subject",
"identity": "w5"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Coverage.subscriberId",
"isSummary": true
}, {
"path": "Coverage.beneficiary",
"requirements": "This is the party who receives treatment for which the costs are reimbursed under the coverage.",
"min": 1,
"definition": "The party who benefits from the insurance coverage; the patient when products and/or services are provided.",
"short": "Plan beneficiary",
"mapping": [ {
"map": "Event.subject",
"identity": "workflow"
}, {
"map": "FiveWs.subject[x]",
"identity": "w5"
}, {
"map": "D01 through D09",
"identity": "cdanetv4"
}, {
"map": "IN1-16, 18, 19-name of insured, address, date of birth",
"identity": "v2"
}, {
"map": "C.35",
"identity": "cpha3pharm"
}, {
"map": "FiveWs.subject",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ]
} ],
"max": "1",
"id": "Coverage.beneficiary",
"isSummary": true
}, {
"path": "Coverage.dependent",
"requirements": "For some coverages a single identifier is issued to the Subscriber and then a unique dependent number is issued to each beneficiary.",
"definition": "A unique identifier for a dependent under the coverage.",
"short": "Dependent number",
"mapping": [ {
"map": "C17",
"identity": "cdanetv4"
}, {
"map": "- No exact HL7 v2 equivalent concept seems to exist;",
"identity": "v2"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Coverage.dependent",
"comment": "Periodically the member number is constructed from the subscriberId and the dependant number.",
"isSummary": true
}, {
"path": "Coverage.relationship",
"requirements": "To determine relationship between the patient and the subscriber to determine coordination of benefits.",
"definition": "The relationship of beneficiary (patient) to the subscriber.",
"short": "Beneficiary relationship to the subscriber",
"mapping": [ {
"map": "C03",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "extensible",
"valueSet": "http://hl7.org/fhir/ValueSet/subscriber-relationship",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Relationship"
} ],
"description": "The relationship between the Subscriber and the Beneficiary (insured/covered party/patient)."
},
"max": "1",
"id": "Coverage.relationship",
"comment": "Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others."
}, {
"path": "Coverage.period",
"requirements": "Some insurers require the submission of the coverage term.",
"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.",
"short": "Coverage start and end dates",
"mapping": [ {
"map": "Event.occurrence[x]",
"identity": "workflow"
}, {
"map": "FiveWs.done[x]",
"identity": "w5"
}, {
"map": "IN1-12 / IN1-13",
"identity": "v2"
}, {
"map": "Act.effectiveTime",
"identity": "rim"
} ],
"type": [ {
"code": "Period"
} ],
"max": "1",
"id": "Coverage.period",
"isSummary": true
}, {
"path": "Coverage.payor",
"requirements": "Need to identify the issuer to target for claim processing and for coordination of benefit processing.",
"min": 1,
"definition": "The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.",
"short": "Issuer of the policy",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": "A05",
"identity": "cdanetv4"
}, {
"map": "IN1-3",
"identity": "v2"
}, {
"map": "C.30",
"identity": "cpha3pharm"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson" ]
} ],
"id": "Coverage.payor",
"comment": "May provide multiple identifiers such as insurance company identifier or business identifier (BIN number).\nFor selfpay it may provide multiple paying persons and/or organizations.",
"isSummary": true
}, {
"id": "Coverage.class",
"path": "Coverage.class",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Additional coverage classifications",
"comment": "For example may be used to identify a class of coverage or employer group, Policy, Plan.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Class"
} ],
"definition": "A suite of underwriter specific classifiers.",
"requirements": "The codes provided on the health card which identify or confirm the specific policy for the insurer."
}, {
"path": "Coverage.class.type",
"requirements": "The insurer issued label for a specific health card value.",
"min": 1,
"definition": "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.",
"short": "Type of class such as 'group' or 'plan'",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "extensible",
"valueSet": "http://hl7.org/fhir/ValueSet/coverage-class",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CoverageClass"
} ],
"description": "The policy classifications, eg. Group, Plan, Class, etc."
},
"max": "1",
"id": "Coverage.class.type",
"isSummary": true
}, {
"path": "Coverage.class.value",
"requirements": "The insurer issued label and value are necessary to identify the specific policy.",
"min": 1,
"definition": "The alphanumeric string value associated with the insurer issued label.",
"short": "Value associated with the type",
"mapping": [ {
"map": "C11 (Division,Section)",
"identity": "cdanetv4"
}, {
"map": "IN1-8",
"identity": "v2"
}, {
"map": "C.31",
"identity": "cpha3pharm"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Coverage.class.value",
"comment": "For example, the Group or Plan number.",
"isSummary": true
}, {
"path": "Coverage.class.name",
"requirements": "Used to provide a meaningful description in correspondence to the patient.",
"definition": "A short description for the class.",
"short": "Human readable description of the type and value",
"mapping": [ {
"map": "C11 (Division,Section)",
"identity": "cdanetv4"
}, {
"map": "IN1-8",
"identity": "v2"
}, {
"map": "C.31",
"identity": "cpha3pharm"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Coverage.class.name",
"isSummary": true
}, {
"path": "Coverage.order",
"requirements": "Used in managing the coordination of benefits.",
"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.",
"short": "Relative order of the coverage",
"mapping": [ {
"map": "- No exact HL7 v2 equivalent concept seems to exist;",
"identity": "v2"
} ],
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Coverage.order",
"isSummary": true
}, {
"path": "Coverage.network",
"requirements": "Used in referral for treatment and in claims processing.",
"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.",
"short": "Insurer network",
"mapping": [ {
"map": "D10",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Coverage.network",
"isSummary": true
}, {
"path": "Coverage.costToBeneficiary",
"requirements": "Required by providers to manage financial transaction with the patient.",
"definition": "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.",
"short": "Patient payments for services/products",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "CostToBeneficiary"
} ],
"alias": [ "CoPay", "Deductible", "Exceptions" ],
"id": "Coverage.costToBeneficiary",
"comment": "For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment."
}, {
"path": "Coverage.costToBeneficiary.type",
"requirements": "Needed to identify the category associated with the amount for the patient.",
"definition": "The category of patient centric costs associated with treatment.",
"short": "Cost category",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "extensible",
"valueSet": "http://hl7.org/fhir/ValueSet/coverage-copay-type",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CopayTypes"
} ],
"description": "The types of services to which patient copayments are specified."
},
"max": "1",
"id": "Coverage.costToBeneficiary.type",
"comment": "For example visit, specialist visits, emergency, inpatient care, etc.",
"isSummary": true
}, {
"path": "Coverage.costToBeneficiary.value[x]",
"requirements": "Needed to identify the amount for the patient associated with the category.",
"min": 1,
"definition": "The amount due from the patient for the cost category.",
"short": "The amount or percentage due from the beneficiary",
"mapping": [ {
"map": "C11 (Division,Section)",
"identity": "cdanetv4"
}, {
"map": "IN1-8",
"identity": "v2"
}, {
"map": "C.31",
"identity": "cpha3pharm"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
}, {
"code": "Money"
} ],
"max": "1",
"id": "Coverage.costToBeneficiary.value[x]",
"comment": "Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.",
"isSummary": true
}, {
"id": "Coverage.costToBeneficiary.exception",
"path": "Coverage.costToBeneficiary.exception",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Exceptions for patient payments",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Exemption"
} ],
"definition": "A suite of codes indicating exceptions or reductions to patient costs and their effective periods.",
"requirements": "Required by providers to manage financial transaction with the patient."
}, {
"path": "Coverage.costToBeneficiary.exception.type",
"requirements": "Needed to identify the exception associated with the amount for the patient.",
"min": 1,
"definition": "The code for the specific exception.",
"short": "Exception category",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/coverage-financial-exception",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CoverageFinancialException"
} ],
"description": "The types of exceptions from the part or full value of financial obligations such as copays."
},
"max": "1",
"id": "Coverage.costToBeneficiary.exception.type",
"isSummary": true
}, {
"id": "Coverage.costToBeneficiary.exception.period",
"max": "1",
"path": "Coverage.costToBeneficiary.exception.period",
"type": [ {
"code": "Period"
} ],
"short": "The effective period of the exception",
"isSummary": true,
"definition": "The timeframe during when the exception is in force.",
"requirements": "Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs."
}, {
"id": "Coverage.subrogation",
"max": "1",
"path": "Coverage.subrogation",
"type": [ {
"code": "boolean"
} ],
"short": "Reimbursement to insurer",
"comment": "Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.",
"definition": "When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs.",
"requirements": "See definition for when to be used."
}, {
"id": "Coverage.contract",
"path": "Coverage.contract",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Contract" ]
} ],
"short": "Contract details",
"mapping": [ {
"map": "D01 through D09",
"identity": "cdanetv4"
}, {
"map": "IN1-16, 18, 19",
"identity": "v2"
}, {
"map": "C.35",
"identity": "cpha3pharm"
} ],
"definition": "The policy(s) which constitute this insurance coverage.",
"requirements": "To reference the legally binding contract between the policy holder and the insurer."
} ]
},
"contact": [ {
"telecom": [ {
"value": "http://hl7.org/fhir",
"system": "url"
} ]
}, {
"telecom": [ {
"value": "http://www.hl7.org/Special/committees/fm/index.cfm",
"system": "url"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource"
}