Stream: implementers
Topic: Coverage
Andrew Ross (Mar 11 2016 at 16:23):
I'm not sure what sub-stream this should go into, but I was looking at Coverage (https://www.hl7.org/fhir/coverage.html) and I saw that under the "search parameters" section, the patient (subscriber) isn't listed. We're hoping to be able to query what insurance provider(s) a patient is using, and so we were thinking we would be able to do GET /Coverage?subscriber=patient-id, but it doesn't seem like that is part of the standard. Anyone familiar with Coverage have any thoughts? I know it's still at maturity level 0 but it doesn't seem like an accidental omission.
Andy Stechishin (Mar 11 2016 at 16:28):
@Andrew Ross if you look at the current (CI) build you will note that subscriber has been renamed to planholder and it is included as a search parameter
Andrew Ross (Mar 11 2016 at 16:28):
ok
Andrew Ross (Mar 11 2016 at 16:28):
thanks!
Andrew Ross (Mar 11 2016 at 16:30):
the new resource at http://hl7-fhir.github.io/coverage.html looks awesome @Andy Stechishin
Andy Stechishin (Mar 11 2016 at 16:32):
@Andrew Ross came from discussions at the WGM in Orlando, @Paul Knapp made all the changes, all I did was point you to the web page :)
Jayashree Surnar (May 22 2017 at 06:42):
hello all, in our ipad app for one of the screen we are capturing the insurance details. for that we are using Coverage Resource. coverage.PNG in this address and phone is related to tinsurance company(Organization).effective date and termination date = coverage period. and GroupId= Coverage.grouping.group. and i'm littile bit confusing with policy No. which filed should i choose for this?
in the Coverage resource they have given like this
(Coverage.grouping.group):
Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify an employer group. May also be referred to as a Policy or Group ID.
so please help.
Thank you.
Sunanda Veeraganti (May 22 2017 at 12:30):
@Jayashree Surnar if you are defining GroupId= Coverage.grouping.group then the Policy No. can be Coverage.grouping.plan. this is the coverage example
Sunanda Veeraganti (May 22 2017 at 12:30):
<group value="CBI35"/>
<groupDisplay value="Corporate Baker's Inc. Local #35"/>
<subGroup value="123"/>
<subGroupDisplay value="Trainee Part-time Benefits"/>
<plan value="B37FC"/>
<planDisplay value="Full Coverage: Medical, Dental, Pharmacy, Vision, EHC"/>
Stefan Lang (May 22 2017 at 13:26):
Wouldn't the policy no. just be an identifier for the Coverage?
Sunanda Veeraganti (May 22 2017 at 20:50):
@Stefan Lang Even I thought the same. However if a policy has group, sub group and plan . Then plan value can be used to capture policy number.
Radu Craioveanu (Mar 04 2018 at 21:21):
Would you condider Aetna Medicare Advantate (Medicare Part C offered by Aetna) best described by a Coverage FHIR resource?
Paul Knapp (Mar 13 2018 at 06:03):
@Sunanda Veeraganti Is the policy number unique to the covered party, the beneficiary - if so it would go in the Coverage.identifier,. If it is actually a 'tag' value assigned to that type of policy then yes use the Coverage.grouping.plan in STU 3. Note that in STU 4 we have changed the structure so it would be Coverage.class.type.code="plan".
@Radu Craioveanu Yes, Medicare advantage plans are regular medical plans offered by private insurers. All types of health insurance are represented by Converage.
David Teirney (Mar 26 2018 at 03:51):
@Sunanda Veeraganti what was the outcome here for you? I'm also now looking about where I'm supposed to be mapping the coverage insurance policy number into the FHIR domain.
Paul Knapp (Apr 03 2018 at 12:04):
@David Teirney @Sunanda Veeraganti Do you mean the member ID (Coverage.identifier) or the id for the policy/plan (Coverage.class with .type='plan', Coverage.class with .value='AB1234')
Brendan Keeler (Jun 14 2021 at 17:55):
When it comes to coverages, the documentation ties it closely to card information. So this begs the question: when does one create a new coverage resources vs update a coverage resource?
For instance, if I lose my card and am issued a new card with a different ID, is that a new resource or an updated one? Or if I have Aetna at my employer, leave that employer for a year, and go back (potentially being assigned the same subscriber ID and such), is it a new coverage?
Cooper Thompson (Jun 14 2021 at 18:23):
@Brendan Keeler - I think the answer is: "whatever the registration staff feel like doing on that day". I.e. I don't think it is a FHIR question at all, but rather a workflow question.
Brendan Keeler (Jun 14 2021 at 18:39):
For sure, in general, from the EHR perspective. I'm generating Coverages from non-FHIR payer sources, so looking at the various data elements and trying to roll them up into EOBs, Coverages, etc and not sure whether to create versioned updates or a bunch of unique resources. Sounds like there's the flexibility to do either
Debbie Bucci (Jun 14 2021 at 18:44):
Believe you should anticipate many coverages over a period of time for a number of reasons. Updates for a particular payer but often more than one.
Last updated: Apr 12 2022 at 19:14 UTC
