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    Class Coverage

    Coverage Class

    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).

    FHIR Specification

    • Short: Insurance or medical plan or a payment agreement
    • Definition: Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.
    • Comment: The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.
    • FHIR Version: 5.0.0

    FHIR Coverage

    Hierarchy (View Summary)

    Implements

    Index

    Constructors

    constructor

    Properties

    identifier? fmStatusEnum status coverageKindEnum kind paymentBy? type_? policyHolder? subscriber? subscriberId? beneficiary dependent? relationship? period? insurer? class_? order? network? costToBeneficiary? subrogation? contract? insurancePlan?

    Methods

    parse getIdentifier setIdentifier addIdentifier hasIdentifier getStatusEnumType setStatusEnumType hasStatusEnumType getStatusElement setStatusElement hasStatusElement getStatus setStatus hasStatus getKindEnumType setKindEnumType hasKindEnumType getKindElement setKindElement hasKindElement getKind setKind hasKind getPaymentBy setPaymentBy addPaymentBy hasPaymentBy getType setType hasType getPolicyHolder setPolicyHolder hasPolicyHolder getSubscriber setSubscriber hasSubscriber getSubscriberId setSubscriberId addSubscriberId hasSubscriberId getBeneficiary setBeneficiary hasBeneficiary getDependentElement setDependentElement hasDependentElement getDependent setDependent hasDependent getRelationship setRelationship hasRelationship getPeriod setPeriod hasPeriod getInsurer setInsurer hasInsurer getClass setClass addClass hasClass getOrderElement setOrderElement hasOrderElement getOrder setOrder hasOrder getNetworkElement setNetworkElement hasNetworkElement getNetwork setNetwork hasNetwork getCostToBeneficiary setCostToBeneficiary addCostToBeneficiary hasCostToBeneficiary getSubrogationElement setSubrogationElement hasSubrogationElement getSubrogation setSubrogation hasSubrogation getContract setContract addContract hasContract getInsurancePlan setInsurancePlan hasInsurancePlan fhirType isEmpty isRequiredFieldsEmpty copy toJSON getText setText hasText getContained setContained addContained hasContained getExtension setExtension hasExtension getExtensionByUrl addExtension removeExtension getModifierExtension setModifierExtension hasModifierExtension getModifierExtensionByUrl addModifierExtension removeModifierExtension resourceType getIdElement setIdElement hasIdElement getId setId hasId getMeta setMeta hasMeta getImplicitRulesElement setImplicitRulesElement hasImplicitRulesElement getImplicitRules setImplicitRules hasImplicitRules getLanguageElement setLanguageElement hasLanguageElement getLanguage setLanguage hasLanguage isResource isDataType isComplexDataType isPrimitive isBooleanPrimitive isStringPrimitive isNumberPrimitive isBigIntPrimitive isDateTimePrimitive copyValues initIdentifier initPaymentBy initSubscriberId initClass initCostToBeneficiary initContract

    Constructors

    Properties

    identifier?: Identifier[]

    Coverage.identifier Element

    FHIR Specification

    • Short: Business identifier(s) for this coverage
    • Definition: The identifier of the coverage as issued by the insurer.
    • Comment: 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.
    • Requirements: Allows coverages to be distinguished and referenced.
    • FHIR Type: Identifier
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: true
    fmStatusEnum: FmStatusEnum

    FHIR CodeSystem: FmStatus

    FmStatusEnum

    status: null | EnumCodeType

    Coverage.status Element

    FHIR Specification

    • Short: active | cancelled | draft | entered-in-error
    • Definition: The status of the resource instance.
    • Comment: This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.
    • Requirements: 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'.
    • FHIR Type: code
    • Cardinality: 1..1
    • isModifier: true
    • isModifierReason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    • isSummary: true

    CodeSystem Enumeration: FmStatusEnum

    coverageKindEnum: CoverageKindEnum

    FHIR CodeSystem: CoverageKind

    CoverageKindEnum

    kind: null | EnumCodeType

    Coverage.kind Element

    FHIR Specification

    • Short: insurance | self-pay | other
    • Definition: The nature of the coverage be it insurance, or cash payment such as self-pay.
    • Requirements: This is used to implement conformance on other elements.
    • FHIR Type: code
    • Cardinality: 1..1
    • isModifier: false
    • isSummary: true

    CodeSystem Enumeration: CoverageKindEnum

    paymentBy?: CoveragePaymentByComponent[]

    Coverage.paymentBy Element

    FHIR Specification

    • Short: Self-pay parties and responsibility
    • Definition: Link to the paying party and optionally what specifically they will be responsible to pay.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false

    Private Optionaltype_

    type_?: CodeableConcept

    Coverage.type Element

    FHIR Specification

    • Short: Coverage category such as medical or accident
    • Definition: The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.
    • Requirements: The order of application of coverages is dependent on the types of coverage.
    • FHIR Type: CodeableConcept
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: true
    policyHolder?: Reference

    Coverage.policyHolder Element

    FHIR Specification

    subscriber?: Reference

    Coverage.subscriber Element

    FHIR Specification

    • Short: Subscriber to the policy
    • Definition: 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.
    • Comment: 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.
    • Requirements: This is the party who is entitled to the benfits under the policy.
    • FHIR Type: Reference
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: true
    subscriberId?: Identifier[]

    Coverage.subscriberId Element

    FHIR Specification

    • Short: ID assigned to the subscriber
    • Definition: The insurer assigned ID for the Subscriber.
    • Requirements: The insurer requires this identifier on correspondance and claims (digital and otherwise).
    • FHIR Type: Identifier
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: true
    beneficiary: null | Reference

    Coverage.beneficiary Element

    FHIR Specification

    • Short: Plan beneficiary
    • Definition: The party who benefits from the insurance coverage; the patient when products and/or services are provided.
    • Requirements: This is the party who receives treatment for which the costs are reimbursed under the coverage.
    • FHIR Type: Reference
    • Cardinality: 1..1
    • isModifier: false
    • isSummary: true
    dependent?: StringType

    Coverage.dependent Element

    FHIR Specification

    • Short: Dependent number
    • Definition: A designator for a dependent under the coverage.
    • Comment: Sometimes the member number is constructed from the subscriberId and the dependant number.
    • Requirements: For some coverages a single identifier is issued to the Subscriber and then an additional dependent number is issued to each beneficiary.
    • FHIR Type: string
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: true
    relationship?: CodeableConcept

    Coverage.relationship Element

    FHIR Specification

    • Short: Beneficiary relationship to the subscriber
    • Definition: The relationship of beneficiary (patient) to the subscriber.
    • Comment: Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.
    • Requirements: The relationship between the patient and the subscriber to determine coordination of benefits.
    • FHIR Type: CodeableConcept
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    period?: Period

    Coverage.period Element

    FHIR Specification

    • Short: Coverage start and end dates
    • Definition: 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.
    • Requirements: Some insurers require the submission of the coverage term.
    • FHIR Type: Period
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: true
    insurer?: Reference

    Coverage.insurer Element

    FHIR Specification

    • Short: Issuer of the policy
    • Definition: The program or plan underwriter, payor, insurance company.
    • Comment: May provide multiple identifiers such as insurance company identifier or business identifier (BIN number).
    • Requirements: Need to identify the issuer to target for claim processing and for coordination of benefit processing.
    • FHIR Type: Reference
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: true

    Private Optionalclass_

    class_?: CoverageClassComponent[]

    Coverage.class Element

    FHIR Specification

    • Short: Additional coverage classifications
    • Definition: A suite of underwriter specific classifiers.
    • Comment: For example, class may be used to identify a class of coverage or employer group, policy, or plan.
    • Requirements: The codes provided on the health card which identify or confirm the specific policy for the insurer.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    order?: PositiveIntType

    Coverage.order Element

    FHIR Specification

    • Short: Relative order of the coverage
    • Definition: 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.
    • Requirements: Used in managing the coordination of benefits.
    • FHIR Type: positiveInt
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: true
    network?: StringType

    Coverage.network Element

    FHIR Specification

    • Short: Insurer network
    • Definition: 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.
    • Requirements: Used in referral for treatment and in claims processing.
    • FHIR Type: string
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: true
    costToBeneficiary?: CoverageCostToBeneficiaryComponent[]

    Coverage.costToBeneficiary Element

    FHIR Specification

    • Short: Patient payments for services/products
    • Definition: 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.
    • Comment: For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.
    • Requirements: Required by providers to manage financial transaction with the patient.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    subrogation?: BooleanType

    Coverage.subrogation Element

    FHIR Specification

    • Short: Reimbursement to insurer
    • Definition: When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs.
    • Comment: Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.
    • Requirements: See definition for when to be used.
    • FHIR Type: boolean
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    contract?: Reference[]

    Coverage.contract Element

    FHIR Specification

    • Short: Contract details
    • Definition: The policy(s) which constitute this insurance coverage.
    • Requirements: To reference the legally binding contract between the policy holder and the insurer.
    • FHIR Type: Reference
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    insurancePlan?: Reference

    Coverage.insurancePlan Element

    FHIR Specification

    • Short: Insurance plan details
    • Definition: The insurance plan details, benefits and costs, which constitute this insurance coverage.
    • Requirements: To associate the plan benefits and costs with the coverage which is an instance of that plan.
    • FHIR Type: Reference
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false

    Methods

    • Parse the provided Coverage JSON to instantiate the Coverage data model.

      Parameters

      • sourceJson: Value

        JSON representing FHIR Coverage

      • OptionaloptSourceField: string

        Optional data source field (e.g. <complexTypeName>.<complexTypeFieldName>); defaults to Coverage

      Returns undefined | Coverage

      Coverage data model or undefined for Coverage

      JsonError if the provided JSON is not a valid JSON object

    • Assigns the provided PolicyHolder object value to the policyHolder property.

      Parameters

      • value: undefined | Reference

        the policyHolder object value

      Returns this

      this

      @ReferenceTargets('Coverage.policyHolder', ['Patient','RelatedPerson','Organization',])

      InvalidTypeError for invalid data type or reference value

    • Assigns the provided value to the text property.

      Parameters

      Returns this

      this

    • Returns boolean

      true if the text property exists and has a value; false otherwise

    • Assigns the provided Resource array value to the contained property.

      Parameters

      • value: undefined | IResource[]

        the contained array value

      Returns this

      this

    • Returns boolean

      true if the contained property exists and has a value; false otherwise

    • Assigns the provided array of Extension values to the extension property.

      Parameters

      • extension: undefined | IExtension[]

        array of Extensions

      Returns this

      this

    • Determines if the extension property exists.

      Parameters

      • Optionalurl: string

        the url that identifies a specific Extension

      Returns boolean

      true if an Extension has the provided url; false otherwise

      If the url is provided, determines if an Extension having the provided url exists. If the url is not provided, determines if the extension property exists and has any values.

      AssertionError for invalid url

    • Adds the provided Extension to the extension property array.

      Parameters

      • extension: undefined | IExtension

        the Extension value to add to the extension property array

      Returns this

      this

    • Removes the Extension having the provided url from the extension property array.

      Parameters

      • url: string

        the url that identifies a specific Extension to remove

      Returns void

      AssertionError for invalid url

    • Determines if the modifierExtension property exists.

      Parameters

      • Optionalurl: string

        the url that identifies a specific Extension

      Returns boolean

      true if an Extension has the provided url

      If the url is provided, determines if an Extension having the provided url exists. If the url is not provided, determines if the modifierExtension property exists and has any values.

      AssertionError for invalid url

    • Assigns the provided PrimitiveType value to the id property.

      Parameters

      • element: undefined | IdType

        the id value

      Returns this

      this

    • Returns undefined | string

      the id property value as a primitive value

    • Assigns the provided primitive value to the id property.

      Parameters

      • value: undefined | string

        the id value

      Returns this

      this

      PrimitiveTypeError for invalid primitive types

    • Returns boolean

      true if the id property exists and has a value; false otherwise

    • Assigns the provided value to the meta property.

      Parameters

      • value: undefined | Meta

        the meta value

      Returns this

      this

    • Returns boolean

      true if the meta property exists and has a value; false otherwise

    • Assigns the provided primitive value to the implicitRules property.

      Parameters

      • value: undefined | string

        the implicitRules value

      Returns this

      this

      PrimitiveTypeError for invalid primitive types

    • Returns undefined | string

      the language property value as a primitive value

    • Assigns the provided primitive value to the language property.

      Parameters

      • value: undefined | string

        the language value

      Returns this

      this

      PrimitiveTypeError for invalid primitive types

    • Returns boolean

      true if the language property exists and has a value; false otherwise

    • Returns boolean

      true if the instance is a FHIR complex or primitive datatype; false otherwise

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