The Coverage resource implements the FHIR R4 Coverage specification

Fields

Name Type Cardinality Required Description  
  identifier Identifier 0..*   Business Identifier for the coverage
  status code 1..1 * active | cancelled | draft | entered-in-error - Financial Resource Status Codes
  type CodeableConcept 0..1   Coverage category such as medical or accident - Coverage Type and Self-Pay Codes
  policyHolder Reference(Patient | RelatedPerson | Organization) 0..1   Owner of the policy
  subscriber Reference(Patient | RelatedPerson) 0..1   Subscriber to the policy
  subscriberId string 0..1   ID assigned to the subscriber
  beneficiary Reference(Patient) 1..1 * Plan beneficiary
  dependent string 0..1   Dependent number
  relationship CodeableConcept 0..1   Beneficiary relationship to the subscriber - SubscriberPolicyholder Relationship Codes
  period Period 0..1   Coverage start and end dates
  payor Reference(Organization | Patient | RelatedPerson) 1..* * Issuer of the policy
  class BackboneElement 0..*   Additional coverage details
  class.type CodeableConcept 1..1 * group
  class.value string 1..1 * Value associated with the type
  class.name string 0..1   Human readable description of the type and value
  order positiveInt 0..1   Relative order of the coverage
  network string 0..1   Insurer network
  costToBeneficiary BackboneElement 0..*   Patient payments for services/products
  costToBeneficiary.type CodeableConcept 0..1   Cost category - Coverage Copay Type Codes
  costToBeneficiary.valueQuantity SimpleQuantity 1..1 * The amount or percentage due from the beneficiary
  costToBeneficiary.valueMoney Money 1..1 * The amount or percentage due from the beneficiary
  costToBeneficiary.exception BackboneElement 0..*   Exceptions for patient payments
  costToBeneficiary.exception.type CodeableConcept 1..1 * Exception category - Example Coverage Financial Exception Codes
  costToBeneficiary.exception.period Period 0..1   The effective period of the exception
  subrogation boolean 0..1   Reimbursement to insurer
  contract Reference(Contract) 0..*   Contract details

Interactions

Read

Get an Coverage entry by id

GET /Coverage/:id

Example

Request

https://r4cert.medicasoft.us/api/fhir/Coverage/12340f5e-7338-6ceb-22ab-68f0ffa1c1b0

Response

{
  "resourceType": "Coverage",
  "identifier": [
    {
      "system": "http://xyz.com/codes/identifier",
      "value": "AB98761"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code": "EHCPOL",
        "display": "extended healthcare"
      }
    ]
  },
  "subscriber": {
    "reference": "Patient/5"
  },
  "subscriberId": "AB9876",
  "beneficiary": {
    "reference": "Patient/5"
  },
  "dependent": "1",
  "relationship": {
    "coding": [
      {
        "code": "self"
      }
    ]
  },
  "period": {
    "start": "2011-03-17",
    "end": "2012-03-17"
  },
  "payor": [
    {
      "reference": "Organization/2"
    }
  ],
  "class": [
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "group"
          }
        ]
      },
      "value": "WESTAIR",
      "name": "Western Airlines"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "plan"
          }
        ]
      },
      "value": "BG4352",
      "name": "Full Coverage: Medical, Dental, Pharmacy, Vision, EHC"
    },
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "subplan"
          }
        ]
      },
      "value": "D15C9",
      "name": "Platinum"
    }
  ],
  "order": 2,
  "network": "5",
  "costToBeneficiary": [
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
            "code": "gpvisit"
          }
        ]
      },
      "valueMoney": {
        "value": 20.00,
        "currency": "USD"
      },
      "exception": [
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/ex-coverage-financial-exception",
                "code": "retired"
              }
            ]
          },
          "period": {
            "start": "2018-01-01",
            "end": "2018-12-31"
          }
        }
      ]
    }
  ],
  "contract": [
    {
      "reference": "Contract/INS-101"
    }
  ],
  "id": "12340f5e-7338-6ceb-22ab-68f0ffa1c1b0"
}

Query Coverage resources

GET /Coverage?:query_parameters

Example

Request

https://r4cert.medicasoft.us/api/fhir/Coverage?patient=123a83df-ee8c-9721-cc07-bdcfc2b1e3f2

Parameters

Name Type Description
beneficiary reference Covered party
class-type token Coverage class (eg. plan, group)
class-value string Value of the class (eg. Plan number, group number)
dependent string Dependent number
identifier token The primary identifier of the insured and the user
patient reference Retrieve coverages for a patient
payor reference The identity of the insurer or party paying for services
policy-holder reference Reference to the policyholder
status token The status of the Coverage
subscriber reference Reference to the subscriber
type token The kind of coverage (health plan, auto, Workers Compensation)
_include   Coverage:payor
_revinclude   MedicationRequest:insurance

Errors

Code Description
400 Invalid parameters
404 Resource not found