Insurance Coverage Summary

When to Use This Skill

Use when a clinician or administrative staff needs detailed insurance coverage information including primary/secondary coordination, coverage periods, subscriber details, and payer contacts.

Clinical Workflow

1. Use fhir_search to retrieve all Coverage resources for the patient (active and inactive)
2. Use fhir_read to retrieve referenced Organization resources (payers) for contact details
3. Organize by coverage order: primary (order=1), secondary (order=2), tertiary
4. Extract plan details from class array: plan name, group number, RX BIN/PCN
5. Identify coverage gaps: periods without active coverage, upcoming coverage end dates
6. Present coordination of benefits summary

FHIR Resources

• Coverage -- Insurance entries: status, type, subscriberId, beneficiary, payor, period, class, order, network
• Organization -- Payer organization details: name, telecom, address
• Patient -- Subscriber vs dependent relationship

FHIR Query Examples

Pull All Coverage

fhir_search(resourceType="Coverage", queryParams="patient=[patient-id]")

Pull Active Coverage Only

fhir_search(resourceType="Coverage", queryParams="patient=[patient-id]&status=active")

Retrieve Payer Organization

fhir_read(resourceType="Organization", id="[payer-organization-id]")

Clinical Guidelines

• CMS requires verification of insurance eligibility before service delivery
• Coordination of benefits rules: primary coverage pays first, secondary covers remaining eligible expenses
• Medicare Secondary Payer rules apply when patient has employer coverage and Medicare

Interpretation Guide

• Present primary coverage first with full plan details, then secondary
• For each coverage: plan name, group number, subscriber ID, coverage period, payer name and phone
• Extract pharmacy benefits separately: RX BIN, RX PCN, RX Group from class array
• Flag: coverage ending within 30 days, no active coverage found, subscriber ID discrepancies between coverages
• Calculate coverage duration and identify any gap periods

Safety

• Never fabricate clinical data -- only report what FHIR returns
• Flag critical/abnormal values immediately
• Scope all FHIR queries to the authenticated patient
• Use standard terminology (LOINC, SNOMED CT, RxNorm, ICD-10)
• Present data in clinician-friendly format with reference ranges