Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.

Coverage provides a link between covered parties (patients) and the payors of their healthcare costs (both insurance and self-pay).

The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.

The identifier of the coverage as issued by the insurer.

Allows coverages to be distinguished and referenced.

The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant. Note that not all insurers issue unique member IDs therefore searches may result in multiple responses.

The status of the resource instance.

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.

The nature of the coverage be it insurance, or cash payment such as self-pay.

This is used to implement conformance on other elements.

Link to the paying party and optionally what specifically they will be responsible to pay.

The list of parties providing non-insurance payment for the treatment costs.

Description of the financial responsibility.

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

The order of application of coverages is dependent on the types of coverage.

The party who 'owns' the insurance policy.

This provides employer information in the case of Worker's Compensation and other policies.

For example: may be an individual, corporation or the subscriber's employer.

The party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due.

This is the party who is entitled to the benfits under the policy.

May be self or a parent in the case of dependants. A subscriber is only required on certain types of policies not all policies and that it is appropriate to have just a policyholder and a beneficiary when not other party can join that policy instance.

The insurer assigned ID for the Subscriber.

The insurer requires this identifier on correspondance and claims (digital and otherwise).

The party who benefits from the insurance coverage; the patient when products and/or services are provided.

This is the party who receives treatment for which the costs are reimbursed under the coverage.

A designator for a dependent under the coverage.

For some coverages a single identifier is issued to the Subscriber and then an additional dependent number is issued to each beneficiary.

Sometimes the member number is constructed from the subscriberId and the dependant number.

The relationship of beneficiary (patient) to the subscriber.

The relationship between the patient and the subscriber to determine coordination of benefits.

Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.

Time period during which the coverage is in force. A missing start date indicates the start date isn't known, a missing end date means the coverage is continuing to be in force.

Some insurers require the submission of the coverage term.

The program or plan underwriter, payor, insurance company.

Need to identify the issuer to target for claim processing and for coordination of benefit processing.

May provide multiple identifiers such as insurance company identifier or business identifier (BIN number).

A suite of underwriter specific classifiers.

The codes provided on the health card which identify or confirm the specific policy for the insurer.

For example, class may be used to identify a class of coverage or employer group, policy, or plan.

The type of classification for which an insurer-specific class label or number and optional name is provided. For example, type may be used to identify a class of coverage or employer group, policy, or plan.

The insurer issued label for a specific health card value.

The alphanumeric identifier associated with the insurer issued label.

The insurer issued label and identifier are necessary to identify the specific policy, group, etc..

For example, the Group or Plan number.

A short description for the class.

Used to provide a meaningful description in correspondence to the patient.

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. For example; a patient might have (0) auto insurance (1) their own health insurance and (2) spouse's health insurance. When claiming for treatments which were not the result of an auto accident then only coverages (1) and (2) above would be applicatble and would apply in the order specified in parenthesis.

Used in managing the coordination of benefits.

The insurer-specific 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.

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.

Required by providers to manage financial transaction with the patient.

For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.

The category of patient centric costs associated with treatment.

Needed to identify the category associated with the amount for the patient.

For example visit, specialist visits, emergency, inpatient care, etc.

Code to identify the general type of benefits under which products and services are provided.

Needed to convey the category of service or product for which eligibility is sought.

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.

Needed as in or out of network providers are treated differently under the coverage.

Indicates if the benefits apply to an individual or to the family.

Needed for the understanding of the benefits.

The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.

Needed for the understanding of the benefits.

The amount due from the patient for the cost category.

Needed to identify the amount for the patient associated with the category.

Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.

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

Required by providers to manage financial transaction with the patient.

The code for the specific exception.

Needed to identify the exception associated with the amount for the patient.

The timeframe the exception is in force.

Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs.

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

See definition for when to be used.

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

The policy(s) which constitute this insurance coverage.

To reference the legally binding contract between the policy holder and the insurer.

The insurance plan details, benefits and costs, which constitute this insurance coverage.

To associate the plan benefits and costs with the coverage which is an instance of that plan.