Langcare Insurance Coverage

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