Coverage

Overview

The Coverage resource describes an individual's insurance coverage or payment information for healthcare services. Coverage is a critical administrative resource that contains information about the individual's insurance plan, subscriber details, and relationship to the subscriber. At its minimum, Coverage contains a status, beneficiary reference, and payor information, but may also include data about the coverage period, policy details, and class/group information.

Each Coverage Must Have:

• health insurance member identifier or subscriber id
• a status
• the health insurance beneficiary (patient)
• beneficiary’s relationship to the subscriber
• the health insurance issuer (payer)

Each Coverage must support:

• health insurance coverage type (e.g., Medicare)
• coverage start and/or end date
• health insurance group and/or plan

Profile specific implementation guidance:

• Coverage.status alone may not indicate whether an individual is covered. The Coverage.period needs to be considered as well. For example, the coverage may be expired with a status of “active”, or conversely, it may be “canceled” but still have covered claims.
• The hierarchical nature of the Coverage.type code system “Payer” (also known as the US Public Health Data Consortium Source of Payment Codes) may be unclear in the expansion, and some of the codes may be inappropriate for the use case. Implementers should refer to the PHDSC Payer Type Committee User’s Guide for the Source of Payment Typology when selecting codes.
• If Insurers issue unique member Ids for dependents, then the memberId Coverage.identifier should be used instead of Coverage.dependent to to uniquely refer to the dependent with respect to their insurance.

This resource conforms to USCDI v3 profile for Coverage * refer to StructureDefinition US Core Coverage. Coverage response will be provided in JSON (refers to Capability Statement) format as per FHIR standard R4 version.

Must support elements, mandatory and optional search parameters

Coverage must support these elements:

• identifier
  • identifier:memberid
    • type
• status
• type
• subscriberId
• beneficiary
• relationship
• period
• payor
• class
  • class:group
    • value
    • name
  • class:plan
    • value
    • name

The following search parameters and search parameter combinations SHALL be supported:

The syntax used to describe the interactions is described here.

SHALL support searching for all coverages for a patient using the patient search parameter: GET [base url]/Coverage?patient={Type/}[id]

The response to any search operation is always a list of resources in a Bundle or an Operation Outcome.

Coverage By Patient Id

Search for coverage by patient id.

METHOD GET

[base url]/Coverage?patient={Type/}[id]

PARAMS [base url] - FHIR base url [id] - Id for the Patient

HEADERS

The Authorization token SHALL be obtained during Authentication and Authorization process. Goto Authentication and Authorization for further details.

Header	Type	Required/Optional	Value
Authorization	string	required	Bearer <token>

RESPONSES

Code	Description	Comment
200	OK	The request was processed successfully
400	Bad request	Invalid request parameters or FHIR operation outcome resource returned
401	Unauthorized	This code indicates that the client request has not been completed because it lacks valid authentication credentials for the requested resource
404	no Route matched with those values	The request was able to communicate with a given server, but the server could not find what was requested
500	Internal Server Error	The server has encountered a situation it doesn't know how to handle

EXAMPLE:

curl --location --request GET 'https://sandbox.fhir.elationemr.com/fhir/Coverage?patient=Patient/c5137fa5-3216-b12a-cbbc-a0c6bef361g7' \
--header 'Authorization: Bearer fe1cd986-1ac7-4c26-b8b3-d632a48408fd'