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Overview

The Coverage resource describes an individual’s insurance coverage or payment information for healthcare services. Coverage is a critical administrative resource that contains information about the individual’s insurance plan, subscriber details, and relationship to the subscriber. At its minimum, Coverage contains a status, beneficiary reference, and payor information, but may also include data about the coverage period, policy details, and class/group information. Each Coverage Must Have:
  • health insurance member identifier or subscriber id
  • a status
  • the health insurance beneficiary (patient)
  • beneficiary’s relationship to the subscriber
  • the health insurance issuer (payer)
Each Coverage must support:
  • health insurance coverage type (e.g., Medicare)
  • coverage start and/or end date
  • health insurance group and/or plan

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Profile specific implementation guidance:

  • Coverage.status alone may not indicate whether an individual is covered. The Coverage.period needs to be considered as well. For example, the coverage may be expired with a status of “active”, or conversely, it may be “canceled” but still have covered claims.
  • The hierarchical nature of the Coverage.type code system “Payer” (also known as the US Public Health Data Consortium Source of Payment Codes) may be unclear in the expansion, and some of the codes may be inappropriate for the use case. Implementers should refer to the PHDSC Payer Type Committee User’s Guide for the Source of Payment Typology when selecting codes.
  • If Insurers issue unique member Ids for dependents, then the memberId Coverage.identifier should be used instead of Coverage.dependent to to uniquely refer to the dependent with respect to their insurance.
This resource conforms to USCDI v3 profile for Coverage * refer to StructureDefinition US Core Coverage. Coverage response will be provided in JSON (refers to Capability Statement) format as per FHIR standard R4 version.

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Must support elements, mandatory and optional search parameters

Coverage must support these elements:
  • identifier
    • identifier:memberid
      • type
  • status
  • type
  • subscriberId
  • beneficiary
  • relationship
  • period
  • payor
  • class
    • class:group
      • value
      • name
    • class:plan
      • value
      • name
The following search parameters and search parameter combinations SHALL be supported: The syntax used to describe the interactions is described here. SHALL support searching for all coverages for a patient using the patient search parameter: GET [base url]/Coverage?patient={Type/}[id] The response to any search operation is always a list of resources in a Bundle or an Operation Outcome.

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Coverage By Patient Id

Search for coverage by patient id. METHOD GET
PARAMS [base url] - FHIR base url [id] - Id for the Patient HEADERS The Authorization token SHALL be obtained during the Authentication and Authorization process. Go to Authentication and Authorization for further details. RESPONSES EXAMPLE: