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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.

FromDefinition
CCIIO Regs§ 150.103 Definitions.
* * * * *
Individual health insurance policy or individual policy means the legal document or contract issued by the issuer to an individual that contains the conditions and terms of the insurance. Any association or trust arrangement that is not a group health plan as defined in § 144.103 of this subchapter or does not provide coverage in connection with one or more group health plans is individual coverage subject to the requirements of parts 147 and 148 of this subchapter. The term ‘‘individual health insurance policy’’ includes a policy that is –
(1) Issued to an association that makes coverage available to individuals other than in connection with one or more group health plans; or
(2) Administered, or placed in a trust, and is not sold in connection with a group health plan subject to the provisions of parts 146 and 147 of this subchapter.
Merriam Webster: a document that contains the agreement that an insurance company and a person have made
Business DictionaryFormal contract-document issued by an insurance company to an insured. It (1) puts an indemnity cover into effect, (2) serves as a legal evidence of the insurance agreement, (3) sets out the exact terms on which the indemnity cover has been provided, and (4) states associated information such as the (a) specific risks and perils covered, (b) duration of coverage, (c) amount of premium, (d) mode of premium payment, and (e) deductibles, if any.

Read more: http://www.businessdictionary.com/definition/insurance-policy.html

An insurance policy is a contract which outlines an insurer’s obligations to a premium-paying party, known as the policy holder.

What is an Insurance Policy? (with pictures) - wiseGEEK
www.wisegeek.com/what-is-an-insurance-policy.htm


Insurance Policy — in broad terms, the entire printed insurance contract. Generally, an insurance policy is assembled with a combination of various standard forms, including a declarations page, coverage form, and endorsements. Sometimes a causes of loss form is also required. Together these forms delineate the coverage term, the insurance policy limits, the grant of coverage, exclusions and other limitations of coverage, and the duties and responsibilities of the insured in the event of a loss.

The legal document issued by the company to the policyholder, which outlines the conditions and terms of the insurance; also called the policy contract or the contract



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.)

 NUCC

Not defined by NAIC

Laurie/1st Pass

Provider

 Not in Coverage


 

 

 

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 individual or organization which has 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

 Organization that arranges/signs off contract with insurance company to provide one or more benefit packages to their employees/sponsored individuals For Tricare, please see subscriber
Insuredsee subscriber, beneficiaryMember, Beneficiary
The 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 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

 

 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 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 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 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 coverageNot represented in FHIR
ServiceCoverage Eligibility ????

Is this benefit covered 

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 be something like "additional qualifiers"?  Does class mean classifiers?


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

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


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.

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)


MOVE


RxBin - Stands for bank identification number, though it doesn't involve banks and is used to accurately route claims to pharmacy benefit managers (PBM).

The pharmacy industry uses RxBin (required), RxPCN (situational) and RxGrp (situational) to identify pharmacy benefit plans.

RxBIN and RxPCN is analogous to the U.S. zip code + 4. RxBIN (or BIN number), is like the 5-digit zip code that determines the routing destination, and RxPCN (or processor control number), is like the +4, providing a more specific destination.

NCPDP Processor ID Number (BIN) is a six-digit number that health plans use to process electronic pharmacy claims if the health plan doesn't use pharmacy benefit cards with a magnetic stripe. Plans that use cards with a magnetic stripe should use the recommended American National Standards Institute (ANSI) Issue Identifier Number (IIN) for processing electronic pharmacy claims. ANSI issues IIN numbers. NCPDP issues the Processor ID Number (BIN).

Approved by Margaret Weiker

?Review at David's request


MOVE

Prescription drug routing information, known as 4Rx data, are the four data elements used to process a pharmacy claims.

In Medicare Part D, these four elements uniquely identify the Medicare Part D Sponsor for the beneficiary and are identified by the sponsor during beneficiary enrollment.

The set of four elements are exchanged with CMS contracted entities during eligibility verification, claims processing, and information reporting transactions, as well as post adjudication claim reporting functions.

The 4Rx data are: RxBIN, RxPCN, RXGRP & RxID. 4Rx data allows payment on behalf of the beneficiary to be counted toward TrOOP. (True Out-of-Pocket costs paid by a beneficiary or others on the beneficiary’s behalf that accumulate towards the annual out-of-pocket threshold)

https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/NCPDP-Pharmacy-Identification-Specifications-Information.pdf

NCPDP BIN: https://ncpdp.org/Resources/NCPDP-Processor-ID-(BIN)

ANSI IIN: https://www.ansi.org/other_services/registration_programs/iin

NCPDP Guidance Documents: https://ncpdp.org/Resources/Guidance-Documents.aspx

NCPDP Pharmacy Card Fact Sheet: https://ncpdp.org/NCPDP/media/pdf/NCPDPpharmacyIdCardFactSheet.pdf

Mapping NCPDP Pharmacy Card to X12N 270/271 (eligibility): https://ncpdp.org/NCPDP/media/pdf/Rx_id_card_map_to_270-271.xlsx

NCPDP Medicare Part D Resources: https://ncpdp.org/Resources/Medicare-Part-D

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. 

Note:  NCPDP defines a processor as: An insurer, a governmental program or another financially responsible entity or a third-party administrator or intermediary contracted on the behalf of those entities which receives prescription drug claims, makes a decision regarding the level of reimbursement to the provider, and transmits a response to the provider submitting a claim.


Approved by Margaret Weiker

MOVE

The PCN appears on the pharmacy ID card with the BIN/IIN in accordance with rules defined in the NCPDP Pharmacy ID and Combination Card Implementation Guide. This document is available with NCPDP membership. General information is available on the Guidance Documents page under the "Pharmacy and Healthcare Identification Cards" banner.

Not all entities use the PCN to differentiate plans. Some entities may use the Group ID; still others may not need this level of differentiation.

Serafina

-Rxid

 Coverage.class.type


 

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


For members who have Medicare part D, this is the patient's member number in the PBM’s system that processes claims

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




MOVE

280.3 For the purposes of the Federal Program Inventory, what is a program?
GAO defined program in the Glossary of Terms Used in the Budget Process as an organized set of activities directed toward a common purpose or goal that an agency undertakes or proposes to carry out its responsibilities. Within this broad definition, agencies and their stakeholders use the term “program” in different ways. Agencies have widely varying missions and achieve these missions through different programmatic approaches, so differences in the use of he term “program” are legitimate and meaningful.
For this reason, this guidance does not prescribe a superseding definition of “program”; rather, consistent with the GPRA Modernization Act, agencies may identify programs consistent with the manner in which the agency uses  programs to interact with key stakeholders and to execute its mission.

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?

General wellness program, asthmatic child program


Example:  Medicare, Medicaid, TriCare, State level services like Family Care which is paid with state or local funding

MOVE

OMB Circular No. A–11 (2015)
AND/or
AO-05-734SP A Glossary of Terms Used in the Federal Budget Process


6/1 notes: separate difference between state/federal organization level (e.g. Medicare) and a plan benefit offering level (e.g. wellness program)

Tony

Product

 


 Program, Plan


 

 

Order

 Coverage.order


 

 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 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?


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 

Type

see above



see above



 

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