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Websites:  https://www.opm.gov/healthcare-insurance/insurance-glossary/

These definitions are for us in HL7 FHIR data standards and assumes no legal or regulatory meaning

DISCUSS purpose of COVERAGE resource

Nomenclature

/Concepts

FHIR element

Related Terms

aka

Definition

Notes/Links               

Who

Policy

Coverage.contract


Contract

Typically an agreement between a policyholder(see policyholder) and an insurer to outline the terms and conditions for coverage and benefits.  However, the agreement may not have been made by the policy holder, for example in the Federally Funded Exchange, a person can purchase insurance for another individual and not be directly covered by that policy.


Mary Kay

Patient

Coverage.beneficiary


beneficiary, subscriber, member, dependent

An individual who has received, is receiving or intends to receive health care services.

(Health care services as defined by federal and state regulations.)


Laurie/1st Pass

Provider

 Not in Coverage


 

  

Narrowed our focus to Coverage Resource

Sonja

Types of Insurance

 Coverage.type


 

 The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.

TypeDescription
Agricultural

Automobile

Casualty

Deposit

Flood

Health
(includes Dental, Vision)


Home Owner/ Residential

Liability

Life & Annuity

Mortgage

Pet

Property

Reinsurance
(Excessive Loss)


Self

Travel

Worker's Compensation


Focus on Healthcare

Mary Kay

Policyholder

 Coverage.policyHolder


 

 The The individual or organization which has arrangedhas arranged? with the insurer to provide insurance for health services for a defined group or a named list of beneficiaries.


4/20/2020:  Chat comment.

from David Riddle to everyone:
https://www.healthinsuranceproviders.com/what-is-a-medical-policyholder/
from David Riddle to everyone:
Interesting summary of one perspective on what is a Policyholder

 Example where it does not work - someone buys coverage for their grandkids but the parent (custodial) is called the policy holder (even if not the person who pays for it)

https://www.healthinsuranceproviders.com/what-is-a-medical-policyholder/

Paul

 Sponsornot defined in Coverage
Subscriber (Tricare) Organization that arranges/signs off contract with insurance company to provide one or more benefit packages to their employees/sponsored individuals

Insuredsee subscriber, beneficiary
Member, BeneficiaryThe party(ies) covered by an insurance policy.
Gail/Laurie

Subscriber

 Coverage.beneficiary


Member, Sponsor(Tricare)

 An individual or entity that selects benefits offered by an entity, such as an employer, government, or insurance company.


Gail/1st Pass

Subscriber Id

Coverage.subscriberId


 

 An An identifier assigned to an individual or entity that selects benefits offered by an entity, such as an employer, government, or insurance company.

 

Gail

Dependent

 Not defined in FHIR - see Subscriber or Beneficiary


Member, Beneficiary

 An individual, other than the subscriber, who has insurance coverage under the benefits selected by a subscriber.  


Gail/1st Pass

Dependent Id

 Coverage.dependent


 

 An An identifier assigned to an individual, other than the subscriber, who has insurance coverage under the benefits selected by a subscriber. 

 

Gail

Member

 Not defined in FHIR - see Subscriber/Beneficiary


Subscriber, Dependent

 Any Any individual covered by the benefits offered by an entity, such as an employer or insurance company.

 

Laurie/1st Pass

Member Id

Not defined in FHIR - see Subscriber Id or Dependent Id

 

 An An identifier associated with any individual covered by the benefits offered by an entity, such as an employer or insurance company.

 

Laurie

Beneficiary

 Coverage.beneficiary


Member, Insured

Any individual that selects or is covered by benefits provided by government programs

 

Linda

Coverage Period

Coverage.period


 

The time frame in which the policy is in force


Gail

Eligibility PeriodNot defined in FHIR

The time frame for when an individual is allowed to enroll in coverage

ServiceCoverage Eligibility ????

Is this benefit covered Not a part of coverage

Payor

 Coverage.payer


Payer, Insurance Company, Third-party Administrator, Repricer 

Public or private party which offers and/or administers health insurance plan(s) or coverage and/or pays claims directly or indirectly.  Examples include:

  • Insurance Company
  • Health Maintenance Organization
  • Medicare
  • Third-party Administrator
  • Repricer

 

David

Class

 Coverage.class


 

 

Should this class be changed to something like "additional qualifiers"?  Does class mean classifiers?  It seems odd that an element called class has a type called class.

Serafina

-Group

 Coverage.class.type


 

A set of individuals that have coverage under a specific insurance or policy.

Note one or more groups may be tied to a specific insurance or policy.

 

 

-Subgroup

 Coverage.class.type


 

 A subset of individuals within a Group

Example Chamber of Commerce which has members in different areas; State employee trust fund but group for example active vs retired employees

 

-Plan

 Coverage.class.type


 Product, 

Program

Health Plan - written promise of coverage given to an individual, family, or group of covered individuals, where a beneficiary is entitled to receive a defined set of health care benefits in exchange for a defined consideration, such as a premium.

We question if this is used on the card?  Should this refer to the Resource - Insurance Plan

see work Bob Dieterle is doing.  ? is this the same as benefit plan as opposed to the Plan which is used to refer to specific health plans, aka insurers 

  1. FHIR-27109

Robin

-Subplan

 Coverage.class.type


 

A subset of a specific suite of benefits.?

? tiering a network.  X network and Y network both in plan but could differentionate benefits

 

-Class

 Coverage.class.type




Is this on an ID card?  Should it exist or is it intended to represent all of the other items listed here

 ? Example:  Board, Executive, General, COBRA.  Maybe used for employees of plan.

 

-Subclass

 Coverage.class.type


 

 

See above 

 

-Sequence

 Coverage.class.type


 

 A sequence number associated with a short-term continuance of the coverage.

 This not a commonly used concept in US healthcare

 Linda

-Rxbin

 Coverage.class.type


BIN ANSI Issuer Identification Number (IIN)

Rx bin

Rxbin

RxIIN

BIN Number

Card Issuer ID or Bank ID Number used for pharmacy network routing.

Note: In version F2 and higher, this has been changed to RXIIN (RX Issuer Identification Number)

Approved by Margaret Weiker

?Review at David's request

Serafina

-Rxpcn

 Coverage.class.type


Processor Control Number

Processor Control Number assigned by the processor and may be secondary identifier used in routing of pharmacy transactions. 

Approved by Margaret Weiker

Serafina

-Rxid

 Coverage.class.type


 

Insurance ID assigned to the cardholder or identification number used by the plan for pharmacy benefits

Approved by Margaret Weiker

Serafina

-Rxgroup

 Coverage.class.type


 

ID assigned to the cardholder group or employer group for pharmacy benefits

Approved by Margaret Weiker

Serafina

Program

 Not currently defined in FHIR


Plan, 

Product

A program is an organized set of activities directed toward a common purpose or goal that an agency/organization undertakes or proposes to carry out its responsibilities. A program is subject to many different contexts that may be address with a qualifier.

The unqualified term of Program is more commonly used for federal and state programs such as Medicare, Medicaid, Tricare and VA that are administered by contracted entities. 

Commercial entities may have incentives that are referred to as programs such as wellness,  smoking cessation, diabetes, etc.  It is the recommendation of this subgroup that these should be explicitly qualified with a term such as Clinical Programs

Not elaborated currently in FHIR Resources, should this be added since it can be on a card. Is it specified in WEDI guide for cards?  Should it be ProgramCode?)

Tony

Product

 


Program, Plan

see Program, Plan


 

 

Order

 Coverage.order


 

 The The order of application of the insurance to health care claims relative to the other insurance policies (Coverages) which an individual may have. This order would generally follow the order convention for Coordination of Benefit and would include consideration of both health care and accident based insurance. 

Element Id Coverage.order
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.

Cardinality 0..1
Type positiveInt
Requirements
Used in managing the coordination of benefits.

? Account Coverage.priority

Definition conflicts with Requirements


"does not imply primary, secondary etc" and "Used in managing the coordination of benefits"

Jira Tracker 

  1. FHIR-27106

Order versus Account Coverage.coverage.priority 

  1. FHIR-27107

Paul

Network

Coverage.network



 The insurer-specific identification of 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.

 Used in referral for treatment and in claims processing.

Bob

CostToBeneficiary

Coverage.CostToBeneficiary



A  suite 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.

valueset below owned by FM - are descriptions good?  missing any? redundant?


-GP Office Visit Copay

Coverage.CostToBeneficiary.type



The copayment for an office visit for a general practitioner of a discipline.

(Draft) Copayment an amount of the total charge allocated to the patient.


-Specialist Office Visit Copay

Coverage.CostToBeneficiary.type



The copayment office visit for a specialist practitioner of a discipline.



-Emergency Copay

Coverage.CostToBeneficiary.type



The copayment for an episode in an emergency department.



-Inpatient Hospital Copay

Coverage.CostToBeneficiary.type



The copayment for an episode of an inpatient hospital stay



-Tele-visit Copay

Coverage.CostToBeneficiary.type



The copayment for a visit held where the patient is remote relative to the practitioner, e.g. by phone, computer or video conference



-Urgent Care Copay

Coverage.CostToBeneficiary.type



The copayment for a visit to an urgent care facility - typically a community care clinic.



-Copay Percentage

Coverage.CostToBeneficiary.type


CoInsurance

A copayment expressed as a percentage of the allowed amount for the products or services cost for which the patient is responsible

Do we need more code values to represent in network and out of network?


-Copay Amount

Coverage.CostToBeneficiary.type



A copayment expressed as a fixed monetary amount for products or services cost for which the patient is responsible.

Do we need more codes values to represent in network and out of network?


-Deductible

Coverage.CostToBeneficiary.type



An amount the patient must pay before the coverage begins to pay in whole or in part for services. This might be done at an individual or family level based on the  policy.

Do we need more codes for deductible, i.e individual deductible, family deductible, in network deductible, out of network deductible? Should there be separate ones for pharmacy?


-Maximum Out of Pocket

Coverage.CostToBeneficiary.type



The maximum monetary amount for products or services which a patient is expected to incur, typically annually.  This might be done at an individual or family level based on the  policy.

Do we need additional code values for family and individual?


-Exception

Coverage.CostToBeneficiary.exception



A suite of codes indicating exceptions or reductions to patient costs and their effective periods.

code set owned by FM - we are not sure these are used in the United States


--Retired Exception

Coverage.CostToBeneficiary.exception.type



Retired persons have all copays and deductibles reduced.

Retired person has all copays and deductibles reduced


--Foster Exception

Coverage.CostToBeneficiary.exception.type



Children in the foster care have all copays and deductibles waived.Children in the foster care have all copays and deductibles waived.


Subrogation

Coverage.subrogation


Reclamation


Subrogation in this use is a flag to indicate that the coverage may need to be pursued for reimbursement for payment by another payer.

When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs.

Note: Boolean value

Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.


Contract

Coverage.contract


Policy

Typically an agreement between a policyholder(see policyholder) and an insurer to outline the terms and conditions for coverage and benefits.  However, the agreement may not have been made by the policy holder, for example in the Federally Funded Exchange, a person can purchase insurance for another individual and not be directly covered by that policy.

From a card perspective, this would not appear on an insurance card.  It may be used in an internal payer system

Is this perhaps intended to represent the Payer ID? (see below for notes on PayerID)


Contract ID?

Contract.identifier



Define - from contract - Unique identifier for this Contract.

Same as above


Payer IDCoverage.??

Identifier defined by a payer and used for many purposes including for exchange of administrative and clinical dataNote:  This might be considered an identifier under Payer but we feel it is an important identifier and may need to be elevated to an element under Coverage

...