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Coverage

Overview​

The Coverage resource represents financial instruments used to reimburse or pay for health care products and services, including both insurance and self-payment arrangements.

Use Cases:

  • Retrieve patient insurance coverage information
  • Verify coverage eligibility and benefits
  • Support claims processing and billing workflows
  • Track insurance payor relationships

Relationships:

  • Patient: References the individual covered by the insurance
  • Organization: May reference the insurance company or payor organization
  • Provenance: Tracks the source and history of coverage information

Resource Schema​

Key Fields:

FieldTypeDescriptionRequired
idstringUnique identifier for the resourceYes
statuscodeCoverage status (active, cancelled, draft, entered-in-error)Yes
typeCodeableConceptCoverage category (medical, dental, mental health, etc.)No
policyHolderReference(Patient/RelatedPerson/Organization)Owner of the policyNo
subscriberReference(Patient/RelatedPerson)Subscriber to the policyNo
beneficiaryReference(Patient)Plan beneficiaryYes
dependentstringDependent numberNo
relationshipCodeableConceptBeneficiary relationship to subscriberNo
periodPeriodCoverage start and end datesNo
payorReference(Organization/Patient/RelatedPerson)[]Issuer of the policyYes
classBackboneElement[]Additional coverage classificationsNo

JSON Example:

{
  "resourceType": "Coverage",
  "id": "example-coverage-id",
  "meta": {
    "lastUpdated": "2023-09-23T21:34:00.000+00:00"
  },
  "identifier": [
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/v2-0203",
            "code": "PI"
          }
        ],
        "text": "ClientID"
      },
      "system": "urn:oid:2.16.840.1.113883.3.3569.5050.1767"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/ValueSet/coverage-type",
        "code": "pay"
      }
    ]
  },
  "beneficiary": {
    "reference": "Patient/example-patient-id",
    "type": "Patient"
  },
  "relationship": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/ValueSet/subscriber-relationship",
        "code": "self",
        "display": "Self"
      }
    ],
    "text": "Self"
  },
  "period": {
    "start": "2023-01-01T12:00:00+00:00"
  }
}

Operations​

The Certified API Coverage resource supports the following operations. However, support varies by the targeted CareRecord or solution.

CareRecord / SolutionCreateReadUpdateSearch
GEHRIMED----
myAvatar-Yes-Yes
myEvolv----
myUnity----
TheraOffice-Yes-Yes

Read: Retrieves a specific Coverage resource by its unique identifier.

  • Endpoint: GET /Coverage/{id}

Search for coverage using various criteria.

GET Method​

Use GET for simple searches with parameters in the query string.

GET /Coverage?parameter=value

POST Method​

Use POST for complex searches with form-encoded parameters.

POST /Coverage/_search
info

Not all Netsmart solutions support Coverage search. See supported operations table above and consult your target solution's documentation for more information.

Search Parameters​

Patient-based Search:

ParameterTypeRequiredDescriptionExample
patientreferenceYesRetrieve coverages for a patientpatient=value
payorreferenceNoThe identity of the insurer or party paying for servicespayor=value
_lastUpdateddateNoOnly return resources which were last updated as specified by the given range_lastUpdated=value
_revincludespecialNoInclude Provenance resource(s) that reference the matched search results. Allowed: "Provenance:target"_revinclude=value

ID-based Search:

ParameterTypeRequiredDescriptionExample
_idstringYesThe ID of the resource_id=value
_lastUpdateddateNoOnly return resources which were last updated as specified by the given range_lastUpdated=value
_revincludespecialNoInclude Provenance resource(s) that reference the matched search results. Allowed: "Provenance:target"_revinclude=value

Examples​

Read Examples:

Read Coverage by ID
curl -X GET https://fhir.netsmartcloud.com/provider/patient-access/v2/{tenant-id}/Coverage/{id} \
    -H "Authorization: Bearer {token}" \
    -H "Accept: application/fhir+json"

Search Examples:

Search by Patient
curl -X POST https://fhir.netsmartcloud.com/provider/patient-access/v2/{tenant-id}/Coverage/_search \
    -H "Authorization: Bearer {token}" \
    -H "Accept: application/fhir+json" \
    -H "Content-Type: application/x-www-form-urlencoded" \
    -d "patient=Patient/123"
Search by Patient and Payor
curl -X POST https://fhir.netsmartcloud.com/provider/patient-access/v2/{tenant-id}/Coverage/_search \
    -H "Authorization: Bearer {token}" \
    -H "Accept: application/fhir+json" \
    -H "Content-Type: application/x-www-form-urlencoded" \
    -d "patient=Patient/123" \
    -d "payor=Organization/insurance-456"

Integration Patterns​

Common Workflows:

  • Retrieve all coverage records for a patient during eligibility verification
  • Filter coverage by payor to identify specific insurance relationships
  • Include provenance data to track coverage information sources
  • Cross-reference with patient demographics for comprehensive coverage view

Related Resources:

  • Patient - Individual covered by the insurance
  • Organization - Insurance company or payor organization
  • Provenance - Source and history tracking

Error Handling​

For detailed error codes and handling procedures, see the Error Handling Guide.

Supported Profiles​

This resource supports the following FHIR profiles as defined in the CapabilityStatement: