Data related to an individual’s insurance coverage for health care.

Data Element

Coverage Type
Category of health care payers. (e.g., Medicare, TRICARE, Commercial Managed Care - PPO)


NCQA Comment on Coverage Type: for USCDI v5

  1. Coverage Type:
NCQA again recommends that ONC adjust the current coverage type element and adopt a hierarchical structure for coverage type to allow for complete information related to the type of coverage a person has, and allow for utility of the data. The structure should include:   Product Line: Commercial, Medicare, Medicaid, Exchange   Product: HMO, POS, PPO, EPO   Benefit: Drug benefit, Mental health benefit     Because there are not multiple data elements in which to store this information, one individual could fall into several categories in Coverage Type. For example, an organization might classify members as enrolled in an HMO, but under the current element, stakeholders would be unable to distinguish if the HMO is a commercial product.   In NCQA’s HEDIS reporting structure, we mitigate this challenge by asking organizations to submit multiple records to indicate if a member is in multiple Coverage Type categories. For example, one member enrolled in a commercial HMO with a drug benefit has three sets of records: one indicating commercial enrollment dates, one indicating HMO enrollment dates, one indicating drug benefit enrollment dates.  It would be more efficient to have one set of records indicating that the member is in Product line: Commercial; Product: HMO; Benefit: Drug. We encourage ONC to consider how to make this data element more granular.

Use of X12 EDI Standards

Given that the health insurance information is used specifically for filing claims or checking eligibility, consistency with the X12 EDI standards on insurance is recommended. 

Unified Comment from CDC

  • Exchange of data element: The Multiple Chronic Conditions eCare Plan project successfully tested this element at the Sep 2020 and Jan 2021 FHIR connectathons and has implemented it at the OHSU testing site.  
  • Applicable Standard:  
  • Additional Use Cases: MedMorph: Central Cancer Registry Reporting Health Care Surveys: PCORnet: Birth Reporting: Multiple Chronic Conditions eCare Pan: This element is used by CMS Quality Reporting and is marked Required or MustSupport in the FHIR QI Core IG

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