Coverage FHIR Resource Proposal

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Coverage

Owning committee name

Financial_Management

Contributing or Reviewing Work Groups

FHIR Resource Development Project Insight ID

994

Scope of coverage

Represents all types of insurance coverage for healthcare-related services. This includes purchased coverage, employer plans, government funded plans, identifiers for state-funded healthcare not modelled/identified as insurance, etc. It includes coverage for humans as well as animals. It also includes extensions and authorizations to existing coverage.

The resource is limited to plans "in effect" for particular individuals or groups of individuals and does not include plan definitions identifying types of coverage that may be available.

RIM scope

Contract class with classCode of COV and moodCode of EVN.

Resource appropriateness

Insurance is a well-understood concept. Coverage of some sort is available for most healthcare services in most jurisdictions. Coverage instances are well identified (often by a cascading set of ids). While the payments offered by some policies may be influenced by the existence of other policies, each policy is independent and can be maintained separately. Coverage information is sometimes maintained directly on patient records, however it is really a distinct thing.

Expected implementations

Referenced by CCDA.

Content sources

  • v2 IN1, IN2, IN3 segments
  • v3 claims models
  • X12
  • NCPDP

Examples

  • Representation of healthcare card
  • National coverage
  • Workers compensation coverage
  • Coverage extension for a particular service

Resource Relationships

Coverage is associated to Patients as covered parties and RelatedPersons as policy holders. Coverage is referenced by Invoices and other financial-related resources

Timelines

Part of initial DSTU

gForge Users

N/A

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