Coverage
This resource represents a financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment..
| Coverage | C | Coverage | There are no (further) constraints on this element Element idCoverageShort description Insurance or medical plan or a payment agreement DefinitionFinancial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment. The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.
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| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idCoverage.idShort description Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case. |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idCoverage.metaShort description Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idCoverage.implicitRulesShort description A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of its narrative along with other profiles, value sets, etc.
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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idCoverage.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). IETF language tag for a human language
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| text | C | 0..1 | Narrative | There are no (further) constraints on this element Element idCoverage.textShort description Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have a narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. The cardinality or value of this element may be affected by these constraints: dom-6 Constraints
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| contained | C | 0..* | Resource | There are no (further) constraints on this element Element idCoverage.containedShort description Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags in their meta elements, but SHALL NOT have security labels. The cardinality or value of this element may be affected by these constraints: dom-2, dom-4, dom-3, dom-5 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.modifierExtensionShort description Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idCoverage.identifierShort description Business identifier(s) for this coverage DefinitionThe 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.
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| status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idCoverage.statusShort description active | cancelled | draft | entered-in-error DefinitionThe 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. A code specifying the state of the resource instance. FinancialResourceStatusCodes (required) Constraints
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| kind | Σ | 1..1 | codeBinding | There are no (further) constraints on this element Element idCoverage.kindShort description insurance | self-pay | other DefinitionThe nature of the coverage be it insurance, or cash payment such as self-pay. This is used to implement conformance on other elements.
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| paymentBy | 0..* | BackboneElement | There are no (further) constraints on this element Element idCoverage.paymentByShort description Self-pay parties and responsibility DefinitionLink to the paying party and optionally what specifically they will be responsible to pay.
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| id | 0..1 | string | There are no (further) constraints on this element Element idCoverage.paymentBy.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.paymentBy.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.paymentBy.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| party | Σ | 1..1 | Reference(Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idCoverage.paymentBy.partyShort description Parties performing self-payment DefinitionThe list of parties providing non-insurance payment for the treatment costs. Reference(Patient | RelatedPerson | Organization) Constraints
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| responsibility | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.paymentBy.responsibilityShort description Party's responsibility DefinitionDescription of the financial responsibility.
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| type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCoverage.typeShort description Coverage category such as medical or accident DefinitionThe 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 type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. CoverageTypeAndSelfPayCodes (preferred) Constraints
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| policyHolder | Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idCoverage.policyHolderShort description Owner of the policy DefinitionThe 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. Reference(Patient | RelatedPerson | Organization) Constraints
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| subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | There are no (further) constraints on this element Element idCoverage.subscriberShort description Subscriber to the policy DefinitionThe 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. Reference(Patient | RelatedPerson) Constraints
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| subscriberId | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idCoverage.subscriberIdShort description ID assigned to the subscriber DefinitionThe insurer assigned ID for the Subscriber. The insurer requires this identifier on correspondance and claims (digital and otherwise).
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| beneficiary | Σ | 1..1 | Reference(Patient) | There are no (further) constraints on this element Element idCoverage.beneficiaryShort description Plan beneficiary DefinitionThe 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.
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| dependent | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.dependentShort description Dependent number DefinitionA 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.
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| relationship | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCoverage.relationshipShort description Beneficiary relationship to the subscriber DefinitionThe 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. The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). SubscriberRelationshipCodes (extensible) Constraints
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| period | Σ | 0..1 | Period | There are no (further) constraints on this element Element idCoverage.periodShort description Coverage start and end dates DefinitionTime 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.
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| insurer | Σ | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idCoverage.insurerShort description Issuer of the policy DefinitionThe 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).
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| class | 0..* | BackboneElement | There are no (further) constraints on this element Element idCoverage.classShort description Additional coverage classifications DefinitionA 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.
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| id | 0..1 | string | There are no (further) constraints on this element Element idCoverage.class.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.class.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.class.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| type | Σ | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCoverage.class.typeShort description Type of class such as 'group' or 'plan' DefinitionThe 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 policy classifications, e.g. Group, Plan, Class, etc. CoverageClassCodes (extensible) Constraints
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| value | Σ | 1..1 | Identifier | There are no (further) constraints on this element Element idCoverage.class.valueShort description Value associated with the type DefinitionThe 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.
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| name | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.class.nameShort description Human readable description of the type and value DefinitionA short description for the class. Used to provide a meaningful description in correspondence to the patient.
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| order | Σ | 0..1 | positiveInt | There are no (further) constraints on this element Element idCoverage.orderShort description Relative order of the coverage DefinitionThe 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.
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| network | Σ | 0..1 | string | There are no (further) constraints on this element Element idCoverage.networkShort description Insurer network DefinitionThe 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.
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| costToBeneficiary | 0..* | BackboneElement | There are no (further) constraints on this element Element idCoverage.costToBeneficiaryShort description Patient payments for services/products Alternate namesCoPay, Deductible, Exceptions DefinitionA 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.
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| id | 0..1 | string | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.typeShort description Cost category DefinitionThe 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. The types of services to which patient copayments are specified. CoverageCopayTypeCodes (extensible) Constraints
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| category | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.categoryShort description Benefit classification DefinitionCode 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. BenefitCategoryCodes (example) Constraints
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| network | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.networkShort description In or out of network DefinitionIs 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.
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| unit | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.unitShort description Individual or family DefinitionIndicates if the benefits apply to an individual or to the family. Needed for the understanding of the benefits.
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| term | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.termShort description Annual or lifetime DefinitionThe term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'. Needed for the understanding of the benefits.
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| value[x] | Σ | 0..1 | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.value[x]Short description The amount or percentage due from the beneficiary DefinitionThe 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.
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| valueQuantity | SimpleQuantity | There are no (further) constraints on this element Data type | ||
| valueMoney | Money | There are no (further) constraints on this element Data type | ||
| exception | 0..* | BackboneElement | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exceptionShort description Exceptions for patient payments DefinitionA suite of codes indicating exceptions or reductions to patient costs and their effective periods. Required by providers to manage financial transaction with the patient.
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| id | 0..1 | string | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| type | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception.typeShort description Exception category DefinitionThe code for the specific exception. Needed to identify the exception associated with the amount for the patient. The types of exceptions from the part or full value of financial obligations such as copays. ExampleCoverageFinancialExceptionCodes (example) Constraints
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| period | Σ | 0..1 | Period | There are no (further) constraints on this element Element idCoverage.costToBeneficiary.exception.periodShort description The effective period of the exception DefinitionThe timeframe the exception is in force. Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs.
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| subrogation | 0..1 | boolean | There are no (further) constraints on this element Element idCoverage.subrogationShort description Reimbursement to insurer DefinitionWhen '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.
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| contract | 0..* | Reference(Contract) | There are no (further) constraints on this element Element idCoverage.contractShort description Contract details DefinitionThe policy(s) which constitute this insurance coverage. To reference the legally binding contract between the policy holder and the insurer.
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| insurancePlan | 0..1 | Reference(InsurancePlan) | There are no (further) constraints on this element Element idCoverage.insurancePlanShort description Insurance plan details DefinitionThe 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.
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