insurance-coverage-summary

Insurance Coverage Summary

Overview

Pull Coverage and Organization resources to produce a consolidated insurance summary. Identify primary and secondary coverage, extract plan details, policy and group numbers, coverage periods, and payor organizations. Flag expired coverage, missing authorization data, coverage gaps, and coordination of benefits issues. Output a structured summary suitable for front-desk verification, prior authorization workflows, or care coordination.

FHIR Resources Used

Instructions

Step 1: Pull All Coverage Resources

Tool: fhir_search
resourceType: "Coverage"
queryParams: "patient=[patient-id]"

Retrieve all Coverage resources regardless of status to capture full history. For each entry extract:

• status: active, cancelled, draft, entered-in-error
• type: Coverage type from type.coding (system http://terminology.hl7.org/CodeSystem/v3-ActCode)
• policyHolder: Reference to the policyholder (may be Patient, RelatedPerson, or Organization)
• subscriber: Reference to the subscriber
• subscriberId: Subscriber ID / Member ID
• beneficiary: Reference to the patient
• dependent: Dependent number
• relationship: Subscriber-to-beneficiary relationship (self, spouse, child, other)
• period: Coverage effective period (start and end dates)
• payor: Reference to the insurance Organization
• class[]: Coverage classification array, each with:
  • type.coding.code: "group", "subgroup", "plan", "subplan", "class", "subclass", "sequence", "rxbin", "rxpcn", "rxid", "rxgroup"
  • value: The identifier value
  • name: Human-readable name
• order: Coverage order (1 = primary, 2 = secondary, 3 = tertiary)
• network: Network name or identifier
• costToBeneficiary[]: Copay and coinsurance information
  • type.coding.code: "copay", "coinsurance", "deductible"
  • valueMoney or valueQuantity