Defining a Coinsurance Percentage in a Coverage Resource

1

When trying to define a percentage for a patients coinsurance on a Coverage Resource, it seems that there is not a corresponding code for “coinsurance”. According to the spec, the “costToBeneficiary” should look something like this:

“costToBeneficiary” : [
{
“type”: {
“coding”: [
{
“system”: “http://terminology.hl7.org/CodeSystem/coverage-copay-type”,
“code”: “coinsurance” // some code to specify coinsurance
}
]
},
“valueQuantity”: {
“value”: “30”,
“unit”: “percent”,
“system”: “http://hl7.org/fhir/ValueSet/ucum-units”,
“code”: “%”
}
}
]

However the following link does not seem to have a code that applies to “coinsurance”, unless this is the intended purpose of “copaypct”.

https://www.hl7.org/fhir/valueset-coverage-copay-type.html

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Is this table missing an appropriate value for “coinsurance” or am I misunderstanding the values/unaware of another value set that applies to this portion of a Coverage?

1 Like
2

The intention here is not to provide a full table of benefits, it is just to provide that information which is conventionally conveyed on the card. Usually the benefit amount (e.g. 80%) and coinsurance (e.g. 20%) are not included on the card.

3

In that case, do you happen to know where the coinsurance info belongs on the Coverage Resource? Im having trouble getting that sorted out.

Thanks for the help!

4

The example at http://www.hl7.org/fhir/coverage-example.json.html captured this information as just an item in the “class” collection, e.g.

{
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
        "code": "subclass"
      }
    ]
  },
  "value": "Tier2",
  "name": "Low deductable, max $20 copay"
},