Coverage dependent on coverage

1

Hello,

Reading about Coverage I have some questions:

Imagine a scenario where both mother and her underage daughter have coverages to an insurance plan.
The mother is responsible to pay monthly to the insurer, while her daughter depends on her.

  • For mother coverage:

    • Should I use her patient id as policyHolder, subscriber, and beneficiary?
    • Should it be saved without a dependent number?

  • For daughter:

    • Should I use the mother patient id as policyHolder, subscriber?
    • Should I use her mother’s card number as subscriber id, while its own number is saved on the dependent number?
    • Should the daughter patient id should be used as beneficiary?

  • When the patients have more than 1 coverage each, should I relate mother-daughter coverages relationships using the subscriber id?

Thanks all

2

Hi Luan,

I would imagine if there is one coverage for both mother and daughter, it would look something long these lines:

For the mother

  ....
      "policyHolder": {
        "reference": "http://benefitsinc.com/FHIR/Organization/CBI35"
      },
      "subscriber": {
        "reference": "Patient/1"       <----- Mother
      },
     "subscriberId": "AB9876",
      "beneficiary": {
        "reference": "Patient/1"       <---- Mother if she is the patient else this would be the daughter
      },
      "dependent": "00",                 <----- Mothers dependent number usually 00 for subscriber and 01, 02,.... for dependents
      "relationship": {
        "coding": [
          {
            "code": "self"                   <---- self or parent etc
          }
        ]
      },
    ....

For the daughter

  ....
      "policyHolder": {
        "reference": "http://benefitsinc.com/FHIR/Organization/CBI35"
      },
      "subscriber": {
        "reference": "Patient/1"  <----- mother's Patient resource
      },
     "subscriberId": "AB9876",
      "beneficiary": {
        "reference": "Patient/2"  <----- child's Patient resource
      },
      "dependent": "01",           <----- different dependent code to mother/subscriber
      "relationship": {
        "coding": [
          {
            "code": "child"
          }
        ]
      },
    ....

If they have more than one Coverage then each coverage will have its own resource with different Policy holders, subscriber id etc but most likely linking to the same Patient resources for the mother, daughter and any other patients/dependents covered by it.

In summary, for your coverage resources details you should be guided by the following:

  "policyHolder" : { Reference(Patient|RelatedPerson|Organization) }, // Owner of the policy which could be the mother or her employer or someone else who owns this policy
  "subscriber" : { Reference(Patient|RelatedPerson) }, // Subscriber to the policy (mother)
  "subscriberId" : "<string>", // ID assigned to the Subscriber (mother's subscriber id)
  "beneficiary" : { Reference(Patient) }, // Plan Beneficiary (mother or patient depending on who is the patient)
  "relationship" : { CodeableConcept }, // Beneficiary relationship to the Subscriber (self if mother or child if we are dealing with the daughter)

Hope this helps

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3

There would be two Coverage resources, one for each of the mother and the child, with both having the same .payor (insurer), .policyHolder (e.g. employer or mom or not supplied), .subscriber (mom’s Patient or RelatedPerson resource), .subscriberID (mom’s subscriber number - may be alphanumeric), .class codes (for ‘plan’ or ‘group’ or ‘rxbin’ etc.) and different .relationship (‘self’ or ‘child’ as above), .identifier (memberId if they have them), .dependent (e.g. as shown above or not supplied if the insurer doesn’t use dependent numbers - may be alphanumeric).

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