Coverage Profile
This Coverage profile is part of the set of resource profiles supported by the API Server used with the athenaPractice 12.3 and athenaFlow 9.12 products. It further describes read, search, create and update capabilities of these products.
Overview
The Coverage resource provides the financial instrument that may be used to pay for or reimburse health care products and services.
Scope and Usage
This profile is used to define the content that will be returned by the API Server in response to requests to access Coverage resources. All elements listed in the differential profile view are Supported, which means that the API Server is capable of supplying these fields from the product database when they have been populated via the product or its APIs.
The profile also defines the content that must be supplied to the API Server in response to requests to populate Coverage resources. Fields which are marked as Mandatory in this profile are those that must be supplied to the API Server in content used to populate a resource.
Source
The Coverage resource is used to information about the patient's insurance coverage. Content of the resource derives from the PatientInsurance table in athenaPractice and the INSURANC table in athenaFlow. Specific detail can be found in the Mappings section below.
Supported Operations
The operations supported by this resource are listed below.
Read Operation
Read operations are executed as specified in the HL7 FHIR RESTful API implementation definition. To read a Coverage, an application shall perform an HTTP GET, specifying the identifier of the resources being retrieved.
GET [base]/fhir/Coverage/[id]{?_format=[json|xml]&_summary=[true|data]}
Read Operation Parameters
| Parameter | Description |
|---|---|
| [base] | Specifies the base URL of the FHIR Server, e.g., https://cpsapisandbox.virenceaz.com:9443/demoAPIServer |
| [id] | Specifies the identifier of the Coverage resource to retrieve |
| [_format] | Specifies the format of the output and may be xml or json. When present, the _format value overrides the value of the Accept header in the request. |
| [_summary] | Filters the output to include only summary elements (_summary=true) or to omit the generated narrative (_summary=data). Note: If the generated html narrative for the resource is not going to be used by the call, using _summary=data provides slightly improved API response times. |
Read Operation HTTP Response Codes
| Response Code | Description |
|---|---|
| 200 OK | The requested resource was found and is contained within the body of the HTTP response. |
| 401 Unauthorized | Authorization is required for this request, and either the Authorization header is missing or the supplied user credentials in the Authorization header are not valid or have expired. The body of the HTTP response will contain an OperationOutcome resource that indicates that Authorization is required. |
| 404 Not Found | The requested resource does not exist. The body of the HTTP response will contain an OperationOutcome resource that indicates that the resource could not be found. |
| 500 Server Error | The server may return other error codes to indicate other error conditions. The body of the HTTP response will contain an OperationOutcome resource that indicates the nature of the error. |
Search Operation
Search operations are executed as specified in the HL7 FHIR RESTful API implementation definition. To search for Coverage resources, an application shall perform an HTTP GET, specifying the query parameters associated with the resource.
GET [base]/fhir/Coverage?{search-parameters}{&_count=[max-results]&_format=[json|xml]&_summary=[true|text|data]}
Search Operation Parameters
| Parameter | Description |
|---|---|
| [base] | Specifies the base URL of the FHIR Server, e.g., https://cpsapisandbox.virenceaz.com:9443/demoAPIServer |
| [_count] | Specifies the maximum number of search results to return in a single query. Note: The count of results does not limit the number of additional resources returned via the _include parameter. No more than max-results Coverage resources which match the search criteria will be returned. The API Server has default and maximum limits for the value that can be specified for this parameter. These limits may vary depending upon the client application vendors participation level in the AthenaHealth Partner program. Note: The API Server support the HL7 FHIR Paging capability. |
| [_format] | Specifies the format of the output and may be xml or json. When present, the _format value overrides the value of the Accept header in the request. |
| [_summary] | Filters the output to include only narrative elements (_summary=text), summary elements (_summary=true) or to omit the generated narrative (_summary=data). Note: If the generated html narrative for the resource is not going to be used by the call, using _summary=data provides improved API response times, especially when returning larger result sets. |
| _id (token ) | The ID of the resource |
| _lastUpdated (date ) | |
| _lastUpdated-fromnow (quantity ) | Like _lastUpdated except expressed as a positive or negative offset from the current time in units of time , e.g. _lastUpdated-fromnow=ge7||d for more than seven days in the future or =le-2||mo for less than two months in the past. The unit must be specified. |
| _security (token ) | |
| group (token ) | Group identifier |
| identifier (token ) | The primary identifier of the insured |
| issuer (reference ) | The identity of the insurer |
| period (date ) | |
| period-fromnow (quantity ) | Like period except expressed as a positive or negative offset from the current time in units of time , e.g. period-fromnow=ge7||d for more than seven days in the future or =le-2||mo for less than two months in the past. The unit must be specified. |
| subscriber (reference ) | |
| type (token ) | The kind of coverage |
Search Operation HTTP Response Codes
| Response Code | Description |
|---|---|
| 200 OK | The query was performed and any results found are contained within the body of the HTTP response. Note: The search API will return 200 OK when the query itself is successful, regardless of whether or not any matching results were found. |
| 401 Unauthorized | Authorization is required for this request, and either the Authorization header is missing or the supplied user credentials in the Authorization header are not valid or have expired. The body of the HTTP response will contain an OperationOutcome resource that indicates that Authorization is required. |
| 500 Server Error | The server may return other error codes to indicate other error conditions. The body of the HTTP response will contain an OperationOutcome resource that indicates the nature of the error. |
Create Operation
Create operations are executed as specified in the HL7 FHIR RESTful API implementation definition. To create a new Coverage resource, an application must perform an HTTP POST, specifying the content of the resource in the body of the request.
POST [base]/fhir/Coverage?{_format=[json|xml]}
Create Operation Parameters
| Parameter | Description |
|---|---|
| [_format] | Specifies the format of the output and may be xml or json. When present, the _format value overrides the value of the Accept header in the request. |
Create Operation HTTP Response Codes
| Response Code | Description |
|---|---|
| 201 Created | The resource was created at the location specified in the HTTP Location header. Note: Unsupported fields will be accepted in a request but will not be persisted to the database. Some fields may be mapped to database specific codes which closely but not perfectly match the input. See the HL7 FHIR specification for more detail on server permitted changes. |
| 400 Bad Request | The resource could not be parsed, or failed basic validation rules. The body of the HTTP response will contain an OperationOutcome resource that provide more detail about the reason for the failure. |
| 401 Unauthorized | Authorization is required for this request, and either the Authorization header is missing or the supplied user credentials in the Authorization header are not valid or have expired. The body of the HTTP response will contain an OperationOutcome resource that indicates that Authorization is required. |
| 422 Unprocessable Entity | The proposed resource violated server business rules. For example, a required field may be missing or a field may contain a value that is not supported by the API Server. The body of the HTTP response will contain an OperationOutcome resource that provide more detail about the reason for the failure. |
| 500 Server Error | The server may return other error codes to indicate other error conditions. The body of the HTTP response will contain an OperationOutcome resource that indicates the nature of the error. |
Update Operation
Update operations are executed as specified in the HL7 FHIR RESTful API implementation definition. To create a new Coverage resource, an application must perform an HTTP PUT, specifying the content of the resource in the body of the request.
PUT [base]/fhir/Coverage/[id]?{_format=[json|xml]}
Update Operation Parameters
| Parameter | Description |
|---|---|
| [_format] | Specifies the format of the output and may be xml or json. When present, the _format value overrides the value of the Accept header in the request. |
Update Operation HTTP Response Codes
| Response Code | Description |
|---|---|
| 200 OK | The resource was updated at the location specified in the HTTP Location header. Note: Unsupported fields will be accepted in a request but will not be persisted to the database. Some fields may be mapped to database specific codes which closely but not perfectly match the input. See the HL7 FHIR specification for more detail on server permitted changes. |
| 400 Bad Request | The resource could not be parsed, or failed basic validation rules. The body of the HTTP response will contain an OperationOutcome resource that provide more detail about the reason for the failure. |
| 401 Unauthorized | Authorization is required for this request, and either the Authorization header is missing or the supplied user credentials in the Authorization header are not valid or have expired. The body of the HTTP response will contain an OperationOutcome resource that indicates that Authorization is required. |
| 422 Unprocessable Entity | The proposed resource violated server business rules. For example, a required field may be missing or a field may contain a value that is not supported by the API Server. The body of the HTTP response will contain an OperationOutcome resource that provide more detail about the reason for the failure. |
| 500 Server Error | The server may return other error codes to indicate other error conditions. The body of the HTTP response will contain an OperationOutcome resource that indicates the nature of the error. |
Profile Content
The official URL for this profile is:
http://hl7.org/fhir/StructureDefinition/coverage-profile
Insurance or medical plan
| Name | Flags | Card. | Type | Description & Constraints | |
|---|---|---|---|---|---|
  Coverage | 0..* | Coverage | Insurance or medical plan | ||
 meta | S ∑ | 0..1 | Meta | Metadata about the resource | |
 implicitRules | ?! ∑ | 0..1 | uri | A set of rules under which this content was created | |
| language | 0..1 | code | Language of the resource content Binding: IETF BCP-47  (required ) | ||
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | ||
 coverage-extension-coverage-type | 0..1 | string | Extension | ||
 url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/coverage-extension-coverage-type" | ||
 valueString | 1..1 | string | Value of extension | ||
| coverage-extension-subscriber-name | 0..1 | HumanName | Extension | ||
| url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/coverage-extension-subscriber-name" | ||
 valueHumanName | 1..1 | HumanName | Value of extension | ||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | |
 issuer | S ∑ | 0..1 | Reference (Organization ) | An identifier for the plan issuer | |
| bin | 0..1 | Identifier | BIN Number | ||
| period | S ∑ | 0..1 | Period | Coverage start and end dates | |
| type | S ∑ | 0..1 | Coding | Type of coverage Binding: ActCoverageTypeCode (example ) | |
| subscriberId | S ∑ | 0..1 | Identifier | Subscriber ID | |
| identifier | S ∑ | 0..* | Identifier | The primary coverage ID | |
| group | S ∑ | 0..1 | string | An identifier for the group | |
| plan | S ∑ | 0..1 | string | An identifier for the plan | |
| subPlan | S ∑ | 0..1 | string | An identifier for the subsection of the plan | |
| dependent | S ∑ | 0..1 | positiveInt | The dependent number | |
| sequence | ∑ | 0..1 | positiveInt | The plan instance or sequence counter | |
| subscriber | ?! | 0..1 | Reference (Patient ) | Plan holder information | |
| network | ∑ | 0..1 | Identifier | Insurer network | |
| contract | 0..* | Reference (Contract ) | Contract details | ||
athenaPractice Mapping
The mappings in this section represent the how data stored within athenaPractice is served through the product's APIs.
athenaPractice and athenaFlow share a common schema for patient clinical data and only one is shown when these are
the same. Use of this information is subject to the API Server
Terms and Conditions .
| Coverage Profile | ||
| Coverage | Coverage-Profile | FHIR_COVERAGEVIEW |
| ├ id | MakeId(%PATIENTINSURANCEID%) | |
| ├ extension | coverage-type | %TYPE% |
| ├ extension | subscriber-name | |
| ├ issuer | MakeReference("INSCARRIER",%INSURANCECARRIERSID%,"Organization", %INSURANCECARRIERNAME%) | |
| ├ period | MakePeriod(%INSCARDEFFECTIVEDATE%,%INSCARDTERMINATIONDATE%) | |
| ├ type | MakeCoding(%ANSI%,getSiteIdSystem("InsuranceCarrierType"),%DESCRIPTION%) | |
| ├ subscriberId | MakeIdentifier("MB",null,%INSUREDID%) | |
| ├ identifier | MakeIdentifier("MB",null,%INSUREDID%) | |
| ├ group | %GROUPID% | |
| └ subscriber | MakeReference("PATIENT",%PID%,"Patient") | |
athenaFlow Mapping
The mappings in this section represent the how data stored within athenaFlow is served through the product's APIs.
Use of this information is subject to the API Server
Terms and Conditions .
| Coverage Profile | ||
| Coverage | Coverage-Profile | FHIR_COVERAGEVIEW |
| ├ id | MakeId(%INSID%) | |
| ├ extension | coverage-type | %TYPE% |
| ├ extension | subscriber-name | |
| ├ issuer | MakeReference("INSCARRIER",%BUSID%,"Organization",%NAME% ) | |
| ├ period | MakePeriod(%EFFECTIVEDATE%,%EXPIREDDATE%) | |
| ├ type | MakeCoding(%CODE%,getSiteIdSystem("InsuranceCarrierType"),%DESCRIPTION%) | |
| ├ subscriberId | MakeIdentifier("MB",null,%IDNO%) | |
| ├ identifier | MakeIdentifier("MB",null,%IDNO%) | |
| ├ group | %GRPNO% | |
| ├ plan | %PLANCODE% | |
| └ subscriber | MakeReference("PATIENT",%PID%,"Patient") | |