Coverage - FHIR Resource (r4)


This Coverage Resource uses the FHIR API standard for access and structure.

Validate an Coverage FHIR Resource (r4)



Resource Attributes

AttributeField is listTypeDescription
beneficiaryfalseReference# Plan beneficiary
classtrueData Type# Additional coverage classifications
contracttrueReference# Contract details
costToBeneficiarytrueData Type# Patient payments for services/products
dependentfalsestring# Dependent number
identifiertrueIdentifier# Business Identifier for the coverage
networkfalsestring# Insurer network
orderfalsepositiveInt# Relative order of the coverage
payortrueReference# Issuer of the policy
periodfalsePeriod# Coverage start and end dates
policyHolderfalseReference# Owner of the policy
relationshipfalseCodeableConcept# Beneficiary relationship to the subscriber
statusfalsecode# active | cancelled | draft | entered-in-error
subrogationfalseboolean# Reimbursement to insurer
subscriberfalseReference# Subscriber to the policy
subscriberIdfalsestring# ID assigned to the subscriber
typefalseCodeableConcept# Coverage category such as medical or accident

Coverage Example

{
  "resourceType": "Coverage",
  "id": "9876B1",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the coverage</div>"
  },
  "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"
    }
  ]
}

Coverage Structure

{
  "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
}

Coverage Search Parameters

The following search parameters can be used to query Coverage resources. Just submit them like so:

https://api.1up.health/fhir/r4/Coverage?query-param=queryvalue
Search ParameterField TypeResource Fields Searched
beneficiaryreferencebeneficiary
class-typetextclass.type
class-valuetextclass.value
dependenttextdependent
identifiertextidentifier
patientreferencebeneficiary
payorreferencepayor
policy-holderreferencepolicyHolder
statustextstatus
subscriberreferencesubscriber
typetexttype