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Coverage

Overview​

The Coverage resource represents financial instruments used to reimburse or pay for healthcare products and services, including insurance plans and self-payment arrangements. This resource is essential for billing and eligibility verification workflows.

Important: Always validate Coverage resource support and available operations by retrieving the current CapabilityStatement from /metadata before implementing integrations.

Resource Schema​

The Coverage resource follows the HL7 FHIR R4 Coverage specification with Netsmart-specific extensions.

Key elements include:

  • status - Active, cancelled, draft, entered-in-error
  • type - Type of coverage (medical, dental, vision, etc.)
  • policyHolder - Owner of the policy
  • subscriber - Subscriber to the policy
  • beneficiary - Plan beneficiary
  • dependent - Dependent number
  • relationship - Beneficiary relationship to subscriber
  • period - Coverage period
  • payor - Issuer of the policy
  • class - Additional coverage classifications

Example Coverage Resource​

{
  "resourceType": "Coverage",
  "id": "12345",
  "status": "active",
  "type": {
    "coding": [{
      "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
      "code": "EHCPOL",
      "display": "Extended Healthcare Policy"
    }]
  },
  "subscriber": {
    "reference": "Patient/12345"
  },
  "beneficiary": {
    "reference": "Patient/12345"
  },
  "relationship": {
    "coding": [{
      "system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
      "code": "self"
    }]
  },
  "period": {
    "start": "2024-01-01",
    "end": "2024-12-31"
  },
  "payor": [{
    "reference": "Organization/insurance-company"
  }],
  "class": [{
    "type": {
      "coding": [{
        "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
        "code": "group"
      }]
    },
    "value": "ABC123",
    "name": "Employee Group Plan"
  }]
}

Supported Profiles​

The API supports the following FHIR profiles:

Operations​

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

CareRecord / SolutionCreateReadUpdateSearch
GEHRIMED----
myAvatarYesYesYesYes
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info

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

This resource supports standard search parameters in addition to the common parameters.

Standard Parameters​

NameTypeDescription
patientreferenceRetrieve coverages for a patient

Custom Parameters​

NameTypeDescription
enddateEnd of active date range.
encounterreferenceUnique identifier of the Practitioner.
startdateStart of active date range.

Search Examples​

Via POST​

The POST method is recommended as it keeps health information out of the URL.

Search by name
curl -X POST https://fhir.netsmartcloud.com/v4/Coverage/_search \
    -H "Authorization: {Bearer Token}" \
    -H "Accept: application/fhir+json" \
    -H "Content-Type: application/x-form-urlencoded" \
    -d "patient=Patient/2345"
Via GET​

The POST method is recommended as it keeps health information out of the URL.

Search by Patient
curl -X POST https://fhir.netsmartcloud.com/v4/Coverage?patient=Patient/2345 \
    -H "Authorization: {Bearer Token}" \
    -H "Accept: application/fhir+json"

Error Handling​

For information about error responses when working with Coverage resources, see Common Errors.

Common Coverage-related errors include:

  • Missing required patient reference
  • Invalid coverage status or type codes
  • Malformed period dates
  • Invalid payor organization references

Integration Patterns​

Eligibility Verification​

Verify patient insurance coverage before services:

# Get active coverage for patient
curl -X GET "https://fhir.netsmartcloud.com/v4/Coverage?patient=12345&status=active" \
    -H "Authorization: Bearer {token}" \
    -H "Accept: application/fhir+json"

Billing Workflows​

Retrieve coverage information for claim processing:

# Get coverage with payor details
curl -X GET "https://fhir.netsmartcloud.com/v4/Coverage/12345?_include=Coverage:payor" \
    -H "Authorization: Bearer {token}" \
    -H "Accept: application/fhir+json"

Encounter-Based Coverage​

Link coverage to specific encounters:

# Get coverage for specific encounter
curl -X GET "https://fhir.netsmartcloud.com/v4/Coverage?encounter=67890" \
    -H "Authorization: Bearer {token}" \
    -H "Accept: application/fhir+json"

Relationships to Other Resources​

The Coverage resource connects to several administrative and clinical resources:

Support​

For questions about Coverage resource implementation or insurance workflow integration, contact Netsmart support through your designated support channels.