Coverage

Overview

The Coverage resource represents insurance or payment information for a patient. It describes the financial coverage a patient has and links to the paying organization.

FHIR R4 Specification

See the official HL7 specification: https://hl7.org/fhir/R4/coverage.html

Supported Fields

Field	Type	Description
id	string	Logical ID of the resource
meta	Meta	Resource metadata
identifier	Identifier[]	Business identifiers
status	code	active, cancelled, draft, entered-in-error
type	CodeableConcept	Coverage type
policyHolder	Reference	Owner of the policy
subscriber	Reference	Subscriber to the policy
subscriberId	string	ID assigned to the subscriber
beneficiary	Reference(Patient)	Plan beneficiary
dependent	string	Dependent number
relationship	CodeableConcept	Beneficiary relationship to subscriber
period	Period	Coverage period
payor	Reference(Organization)[]	Insurance company
class	BackboneElement[]	Classification of coverage
order	positiveInt	Order of application
network	string	Insurer network
costToBeneficiary	BackboneElement[]	Cost sharing amounts
subrogation	boolean	Subrogation applies
contract	Reference(Contract)[]	Contract details

Search Parameters

Parameter	Type	Description	Example
_id	token	Resource ID	_id=cov-001
identifier	token	Business identifier	identifier=COV-12345
patient	reference	Patient reference	patient=Patient/123
beneficiary	reference	Beneficiary	beneficiary=Patient/123
status	token	Coverage status	status=active
type	token	Coverage type	type=HIP
payor	reference	Payor	payor=Organization/456
subscriber	reference	Subscriber	subscriber=Patient/123
policy-holder	reference	Policy holder	policy-holder=Patient/123
class-type	token	Class type	class-type=group
class-value	string	Class value	class-value=EMPLOYER-001

Examples

Create a Coverage

curl -X POST http://localhost:8080/baseR4/Coverage \
  -H "Content-Type: application/fhir+json" \
  -d '{
    "resourceType": "Coverage",
    "status": "active",
    "type": {
      "coding": [{
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code": "HIP",
        "display": "Health insurance plan policy"
      }]
    },
    "subscriber": {
      "reference": "Patient/patient-001"
    },
    "beneficiary": {
      "reference": "Patient/patient-001"
    },
    "relationship": {
      "coding": [{
        "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
        "code": "self",
        "display": "Self"
      }]
    },
    "period": {
      "start": "2024-01-01",
      "end": "2024-12-31"
    },
    "payor": [{
      "reference": "Organization/insurance-001",
      "display": "Blue Cross Blue Shield"
    }],
    "class": [
      {
        "type": {
          "coding": [{
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "group"
          }]
        },
        "value": "EMPLOYER-001",
        "name": "Employer Group Plan"
      },
      {
        "type": {
          "coding": [{
            "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
            "code": "plan"
          }]
        },
        "value": "GOLD",
        "name": "Gold Plan"
      }
    ],
    "network": "PPO Network"
  }'

Search Coverage

# By patient
curl "http://localhost:8080/baseR4/Coverage?patient=Patient/123"

# Active coverage
curl "http://localhost:8080/baseR4/Coverage?status=active"

# By payor
curl "http://localhost:8080/baseR4/Coverage?payor=Organization/456"

Patient Compartment

# Get all coverage for a patient
curl "http://localhost:8080/baseR4/Patient/123/Coverage"

Status Codes

Code	Display
active	Active
cancelled	Cancelled
draft	Draft
entered-in-error	Entered in Error

Coverage Types

Code	Display
HIP	Health insurance plan policy
EHCPOL	Extended healthcare
HSAPOL	Health spending account
AUTOPOL	Automobile
COL	Collision coverage
UNINSMOT	Uninsured motorist
PUBLICPOL	Public insurance
DENTPRG	Dental program
DRUGPOL	Drug policy
MCPOL	Managed care policy
MENTPOL	Mental health policy
VISPOL	Vision care policy