Coverage - FHIR Resource (r4)
This Coverage Resource uses the FHIR API standard for access and structure.
Validate an Coverage FHIR Resource (r4)
Coverage Attributes
AttributeField is listTypeDescription
Description: Business Identifier for the coverage
FHIR Version: r4
Attribute Type : Identifier
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"identifier": [
{
"system": "http://benefitsinc.com/certificate",
"value": "12345"
}
]Learn more about the (Coverage) identifier FHIR attribute
Description: active | cancelled | draft | entered-in-error
FHIR Version: r4
Attribute Type : code
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"status": "active"Learn more about the (Coverage) status FHIR attribute
Description: Coverage category such as medical or accident
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code": "EHCPOL",
"display": "extended healthcare"
}
]
}Learn more about the (Coverage) type FHIR attribute
Description: Owner of the policy
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"policyHolder": {
"reference": "http://benefitsinc.com/FHIR/Organization/CBI35"
}Learn more about the (Coverage) policyHolder FHIR attribute
Description: Subscriber to the policy
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"subscriber": {
"reference": "Patient/4"
}Learn more about the (Coverage) subscriber FHIR attribute
Description: ID assigned to the subscriber
FHIR Version: r4
Attribute Type : string
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"subscriberId": Learn more about the (Coverage) subscriberId FHIR attribute
Description: Plan beneficiary
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"beneficiary": {
"reference": "Patient/4"
}Learn more about the (Coverage) beneficiary FHIR attribute
Description: Dependent number
FHIR Version: r4
Attribute Type : string
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"dependent": "0"Learn more about the (Coverage) dependent FHIR attribute
Description: Beneficiary relationship to the subscriber
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"relationship": {
"coding": [
{
"code": "self"
}
]
}Learn more about the (Coverage) relationship FHIR attribute
Description: Coverage start and end dates
FHIR Version: r4
Attribute Type : Period
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"period": {
"start": "2011-05-23",
"end": "2012-05-23"
}Learn more about the (Coverage) period FHIR attribute
Description: Issuer of the policy
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"payor": [
{
"reference": "Organization/2"
}
]Learn more about the (Coverage) payor FHIR attribute
Description: Additional coverage classifications
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"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"
}
]Learn more about the (Coverage) class FHIR attribute
Description: Relative order of the coverage
FHIR Version: r4
Attribute Type : positiveInt
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"order": Learn more about the (Coverage) order FHIR attribute
Description: Insurer network
FHIR Version: r4
Attribute Type : string
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"network": Learn more about the (Coverage) network FHIR attribute
Description: Patient payments for services/products
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"costToBeneficiary": Learn more about the (Coverage) costToBeneficiary FHIR attribute
Description: Reimbursement to insurer
FHIR Version: r4
Attribute Type : boolean
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"subrogation": Learn more about the (Coverage) subrogation FHIR attribute
Description: Contract details
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"contract": Learn more about the (Coverage) contract FHIR attribute
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 Parameter | Field Type | Resource Fields Searched |
|---|---|---|
beneficiary | reference | beneficiary |
class-type | text | class.type |
class-value | text | class.value |
dependent | text | dependent |
identifier | text | identifier |
patient | reference | beneficiary |
payor | reference | payor |
policy-holder | reference | policyHolder |
status | text | status |
subscriber | reference | subscriber |
type | text | type |
