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The FHIR 4.0 Coverage Resource can be found here:  http://hl7.org/fhir/coverage.html

Crosswalk Table

Name

Flags

Card.

Type

US Realm Industry Term

Description & Constraints

 Coverage

TU


DomainResource


Insurance or medical plan or a payment agreement
Elements defined in Ancestors: idmetaimplicitRuleslanguagetextcontainedextensionmodifierExtension

 identifier

Σ

0..*

Identifier

Member Identifier

Business Identifier for the coverage

May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.

 status

?!Σ

1..1

code


active | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)

 type

Σ

0..1

CodeableConcept


Coverage category such as medical or accident
Coverage Type and Self-Pay Codes (Preferred)

 policyHolder

Σ

0..1

Reference(Patient | RelatedPerson | Organization)


Owner of the policy

 subscriber

Σ

0..1

Reference(Patient | RelatedPerson)


Subscriber to the policy

 subscriberId

Σ

0..1

string

Subscriber Identifier or Subscriber Number

ID assigned to the subscriber

 beneficiary

Σ

1..1

Reference(Patient)

Person receiving treatment

Plan beneficiary

 dependent

Σ

0..1

string

Dependent number

Dependent Sequence

Dependent number

Example:  Mom has policy through her work, husband and 2 children under 10 covered

Mom is -01

Husband -03

Child 1 is -04

Child 2 is -05

 relationship


0..1

CodeableConcept


Beneficiary relationship to the subscriber
SubscriberPolicyholder Relationship Codes (Extensible)


 period

Σ

0..1

Period


Coverage start and end dates

 payor

Σ

1..*

Reference(Organization | Patient | RelatedPerson)


Issuer of the policy










Examples

Examples can be found here:

Dental:  http://hl7.org/fhir/claim-example-oral-contained.json.html

Medical:  http://hl7.org/fhir/claim-example-cms1500-medical.json.html

<snipit> from the examples:

  },

    {

      "resourceType": "Coverage",

      "id": "coverage-1",

      "identifier": [

        {

          "system": "http://benefitsinc.com/certificate",

          "value": "10138556"

        }

      ],

      "status": "active",

      "type": {

        "coding": [

          {

            "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",

            "code": "HIP",

            "display": "health insurance plan policy"

          }

        ]

      },

      "subscriber": {

        "reference": "#patient-1"

      },

      "beneficiary": {

        "reference": "#patient-1"

      },

      "relationship": {

        "coding": [

          {

            "code": "self"

          }

        ]

      },

      "period": {

        "start": "2015-01-01T00:00:00-07:00",

        "end": "2016-01-01T00:00:00-07:00"

      },

      "payor": [

        {

          "identifier": {

            "system": "http://www.bindb.com/bin",

            "value": "123456"

          },

          "display": "Humana Inc."

        }

      ],

      "class": [

        {

          "type": {

            "coding": [

              {

                "system": "http://terminology.hl7.org/CodeSystem/coverage-class",

                "code": "group"

              }

            ]

          },

          "value": "80902206"

        }

      ]

    }

  ],



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