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  1. FHIR Specification Feedback
  2. FHIR-34671

Provide an example of concepts defined by the use case page

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    • Change Request
    • Status: Resolved - No Change (View Workflow)
    • Highest
    • Resolution: Not Persuasive
    • US CARIN Digital Insurance Card (DIC) (FHIR)
    • 0.1.0
    • Payer/Provider Information Exchange
    • Use Case
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      We recognize the terms in the insurance industry can often be confusing, and the way they are defined in the insurance industry does not always line up with the way HL7 names or defines the fields in the FHIR data structure. A Beneficiary is, strictly speaking, an individual covered by a government-sponsored health plan such as Medicare or Medicaid. Typically commercial insurers do not refer to their covered individuals as beneficiaries but rather refer to them as members of the health plan; members can be further classified as subscriber (the person who purchases the plan) and dependents (additional members of the "family" who are covered by the plan). The HL7 FHIR definition of the field named "Coverage.beneficiary" allows for represntation of anyone who is considered a party with health insurance coverage, which covers any of these concepts. The HL7 FHIR Patient resource can be used to represent any individual human or animal regardless of their insurance coverage.

      We responded to FHIR-34682 asking us to clarify how the IG's definition may vary from that of the base resource (Coverage.beneficiary) and believe that the changes we proposed will likely address this ticket as well.

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      We recognize the terms in the insurance industry can often be confusing, and the way they are defined in the insurance industry does not always line up with the way HL7 names or defines the fields in the FHIR data structure. A Beneficiary is, strictly speaking, an individual covered by a government-sponsored health plan such as Medicare or Medicaid. Typically commercial insurers do not refer to their covered individuals as beneficiaries but rather refer to them as members of the health plan; members can be further classified as subscriber (the person who purchases the plan) and dependents (additional members of the "family" who are covered by the plan). The HL7 FHIR definition of the field named "Coverage.beneficiary" allows for represntation of anyone who is considered a party with health insurance coverage, which covers any of these concepts. The HL7 FHIR Patient resource can be used to represent any individual human or animal regardless of their insurance coverage. We responded to FHIR-34682 asking us to clarify how the IG's definition may vary from that of the base resource (Coverage.beneficiary) and believe that the changes we proposed will likely address this ticket as well.
    • Mark Roberts/Durwin Day: 14-0-0

    Description

      Section 3.1 defines a number of terms and concepts, many of which may be similar (eg member, dependent, patient and beneficiary). It's not clear if these are all unique terms or if some can be considered synonyms. For example, Coverage.beneficiary is described as the "patient" (and references a Patient resource). How is this usage of "beneficiary" different than the concept defined in Section 3.1?

      An example using an example family (or some other set of individuals sharing a coverage) may help clarify these concepts for readers. 

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              craig.newman Craig Newman
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                Updated:
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