Coverage — Insurance coverage

The resource that describes a patient's health insurance contract. Pivot of FHIR financial flows: pre-authorization, billing, reimbursement.

Purpose of the resource

Coverage represents one insurance coverage: private health insurance, supplemental / secondary plan, public program (Medicare, Medicaid, Securite sociale, NHS), workers' compensation insurance, travel insurance. A Coverage resource corresponds to a single coverage line; a patient may carry several active Coverages (primary + secondary + tertiary).

Coverage is the central piece of FHIR financial flows. It is referenced by Claim (reimbursement request), ClaimResponse, EligibilityRequest, ExplanationOfBenefit. It also carries cost-sharing (co-payments, deductibles, out-of-pocket maximum) on the patient side.

Key fields

Primary vs secondary coverage

A patient may hold several active Coverages simultaneously. The order field determines the application order:

• order=1 — primary coverage. Receives the reimbursement claim first.
• order=2 — secondary coverage (supplemental / "mutuelle" in France, secondary insurance in the US). Fills the remainder after primary reimbursement.
• order=3+ — tertiary coverages (rare, but exists for specific programs like CMU-C or travel insurance).

In a Claim, you add one Claim.insurance per Coverage, with focal=true for the coverage on which payment is requested (typically the primary). Coordination of benefits (COB) between primary and secondary is tracked via successive ClaimResponses.

JSON example

Primary coverage Aetna PPO 2026 for Patient "example", self-beneficiary, plan "ACME Group", co-pay USD 20 for primary care office visits:

{
  "resourceType": "Coverage",
  "id": "primary-aetna",
  "status": "active",
  "kind": "insurance",
  "type": {
    "coding": [{
      "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
      "code": "EHCPOL",
      "display": "extended healthcare"
    }]
  },
  "policyHolder": { "reference": "Patient/example" },
  "subscriber": { "reference": "Patient/example" },
  "subscriberId": [{
    "value": "W123456789"
  }],
  "beneficiary": { "reference": "Patient/example" },
  "dependent": "01",
  "relationship": {
    "coding": [{
      "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
      "code": "self"
    }]
  },
  "period": {
    "start": "2026-01-01",
    "end": "2026-12-31"
  },
  "insurer": { "reference": "Organization/aetna" },
  "class": [{
    "type": {
      "coding": [{
        "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
        "code": "group"
      }]
    },
    "value": "GRP-2026-ACME",
    "name": "ACME Group Plan"
  }, {
    "type": {
      "coding": [{
        "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
        "code": "plan"
      }]
    },
    "value": "PLN-PPO-2026",
    "name": "Aetna PPO Standard 2026"
  }],
  "order": 1,
  "costToBeneficiary": [{
    "type": {
      "coding": [{
        "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type",
        "code": "gpvisit",
        "display": "GP Office Visit"
      }]
    },
    "valueQuantity": {
      "value": 20,
      "code": "USD",
      "system": "urn:iso:std:iso:4217"
    }
  }]
}

• kind=insurance — commercial coverage (vs self-pay).
• type EHCPOL — extended healthcare policy.
• subscriber=beneficiary=policyHolder — patient is policy holder, subscriber and beneficiary (self-coverage).
• relationship.code=self.
• class[] two entries: group (ACME employer) + plan (Aetna PPO Standard 2026).
• order=1 — primary coverage.
• costToBeneficiary[0] — USD 20 co-pay for primary care visits.

REST API

• GET /Coverage?beneficiary=Patient/example&status=active — active coverages for a patient.
• GET /Coverage?beneficiary=Patient/example&_sort=order — coverages sorted by application order.
• POST /Coverage — create a new coverage after eligibility check.
• GET /Coverage/$eligibility-by-identifier — composite operation (per profile) for real-time eligibility check.
• GET /Coverage?subscriber-id=W123456789 — search by subscriber number.
• GET /Coverage?_include=Coverage:insurer — include the issuing Organization.

National profiles

Common pitfalls

• Confusing subscriber and beneficiary — subscriber can be a parent covering a child. beneficiary is always the current patient receiving care.
• No period.end — a Coverage without an end date appears active indefinitely; manage contract end via status=cancelled + filling period.end.
• Missing order — without order, the EHR cannot determine which coverage to bill first. Always populate when several coverages coexist.
• Inconsistent class — class[].type codes are standardised (group, plan, subgroup, subclass, subplan, class, sequence, rxbin, rxpcn, rxid…). Inventing a proprietary code breaks interop.
• Wrong kind — new in R5. Before R5, this concept lived inside type. kind=self-pay is explicit for uninsured patients, do not omit.
• Active coverage after contract end — a nightly reconciliation job must flip status to cancelled when period.end has passed; otherwise pre-authorisations rely on an expired coverage.

Related resources

• Claim — reimbursement request referencing Coverage.
• ClaimResponse — insurer's response.
• ExplanationOfBenefit — explanation of benefits.
• CoverageEligibilityRequest / CoverageEligibilityResponse — real-time eligibility verification.
• Patient — coverage beneficiary.
• Organization — insurer.
• InsurancePlan — insurance plan details (mutualisation).
• HL7 v2 IN1 / IN2 / IN3 — legacy equivalents.