PatientCoverage

Health insurance coverage information for a patient, including policy details, coverage periods, and subscriber relationships. Essential for billing, eligibility verification, and claims processing.

Overview

PatientCoverage tracks a patient's health insurance policies and their relationship to those policies. Patients may have multiple coverage records (primary, secondary, supplemental) and may be either the policy subscriber or a dependent. The entity links to the insurer organization, policy identifiers, and captures coverage validity periods for eligibility determination.

Key Concepts

Coverage Hierarchy

Patients often have multiple insurance policies that must be coordinated:

Type	Order	Description
Primary	1st	First payer - billed before other insurance
Secondary	2nd	Billed after primary pays or denies
Tertiary	3rd	Billed after primary and secondary
Supplemental	Variable	Covers specific gaps (dental, vision, Medigap)

Policy Identification

The identifier via Identifier contains:

system - Insurance company identifier system
value - Policy/member ID number
period - Coverage validity dates (start/end)

Subscriber Relationships

When patient is not the policy holder:

subscriber - The primary policy holder via Person
subscriberRelationship - How patient relates to subscriber via PatientRelationshipType

Common subscriber relationships:

Spouse - Patient is spouse of subscriber
Child/Dependent - Patient is child of subscriber
Self - Patient is the subscriber

Coverage Status

The calculated field isActive determines current coverage validity based on the identifier.period dates.

Use Cases

Insurance Verification

Before appointment or procedure:

Query patient's coverage records
Check isActive for current validity
Verify primary coverage details with insurer
Confirm patient eligibility and benefits
Document verification results

Claims Submission

When billing for services:

Identify primary coverage for first claim
Submit claim with policy identifier
Wait for primary EOB (Explanation of Benefits)
Bill secondary coverage if applicable
Coordinate benefits according to hierarchy

Patient Registration

During intake:

Collect insurance card information
Create/update coverage records
Verify subscriber if patient is dependent
Set coverage type (primary/secondary)
Confirm coverage period dates

Coverage Coordination

When patient has multiple insurances:

Determine primary based on coordination rules
Set correct coverageType for each policy
Document subscriber relationships
Update when employment or family status changes

Eligibility Checking

For real-time verification:

Use identifier to query insurer systems
Verify coverage is active for service date
Check specific benefit coverage
Confirm copay/deductible amounts
Update isActive status if changed

Related Entities

Entity	Relationship	Description
Patient	Belongs to	The patient covered by this insurance
Organization	References	The insurance company providing coverage
Identifier	Contains	Policy number and validity period
Person	References	The policy subscriber if different from patient
PatientRelationshipType	References	Patient's relationship to the subscriber

Calculated Fields

Field	Type	Description
`isActive`	boolean	True if current date falls within `identifier.period`

Enums

coverageType

Value	Description
`primary`	Primary insurance - billed first for all claims
`secondary`	Secondary insurance - billed after primary processes claim
`tertiary`	Tertiary insurance - billed after primary and secondary
`supplemental`	Supplemental coverage for specific benefits (dental, vision, gap coverage)

8 properties

Schema

Properties

Property	Type	Mode	Description	Required
patient	Patient	stored	Patient covered by this insurance	Required
insurer	Organization	stored	Insurance organization providing coverage	Required
identifier	Identifier	stored	Policy identifier including number and validity period	Required
planName	string	stored	Name of the insurance plan Example: `"Gold PPO Plan"`	Optional
coverageType	string	stored	Type of coverage in relation to other insurance Values: `primary, secondary, tertiary, supplemental` Example: `"primary"`	Required
subscriber	Person	stored	Primary subscriber if different from patient	Optional
subscriberRelationship	PatientRelationshipType	stored	Relationship of patient to the subscriber	Optional
isActive	boolean	calculated	Whether coverage is currently active based on identifier period	Optional

Examples

Example 1

{
  "@type": "PatientCoverage",
  "patient": {
    "@type": "Patient",
    "givenName": "John",
    "familyName": "Smith"
  },
  "insurer": {
    "@type": "Organization",
    "name": "Blue Cross Blue Shield"
  },
  "identifier": {
    "@type": "Identifier",
    "system": "BCBS",
    "value": "BCBS-123456789",
    "type": "financial",
    "label": "Policy Number",
    "period": {
      "@type": "Period",
      "startDate": "2024-01-01",
      "endDate": "2024-12-31"
    }
  },
  "planName": "Gold PPO Plan",
  "coverageType": "primary"
}

Example 2

{
  "@type": "PatientCoverage",
  "patient": {
    "@type": "Patient",
    "givenName": "Sarah",
    "familyName": "Johnson"
  },
  "insurer": {
    "@type": "Organization",
    "name": "Aetna"
  },
  "identifier": {
    "@type": "Identifier",
    "system": "AETNA",
    "value": "AET-987654321",
    "type": "financial",
    "label": "Member ID",
    "period": {
      "@type": "Period",
      "startDate": "2024-01-01",
      "endDate": "2024-12-31"
    }
  },
  "planName": "Family Health Plus",
  "coverageType": "primary",
  "subscriber": {
    "@type": "Person",
    "givenName": "Robert",
    "familyName": "Johnson"
  },
  "subscriberRelationship": {
    "@type": "PatientRelationshipType",
    "code": "PARENT",
    "label": "Parent",
    "category": "family"
  }
}