| name | langcare-insurance-coverage |
| description | Retrieves and analyzes insurance coverage from FHIR Coverage and Organization resources including coordination of benefits, coverage gaps, and eligibility details. Use when asked about insurance info, coverage details, benefits check, coordination of benefits, coverage verification, or payer information.
|
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
- Use
fhir_search to retrieve all Coverage resources for the patient (active and inactive)
- Use
fhir_read to retrieve referenced Organization resources (payers) for contact details
- Organize by coverage order: primary (order=1), secondary (order=2), tertiary
- Extract plan details from class array: plan name, group number, RX BIN/PCN
- Identify coverage gaps: periods without active coverage, upcoming coverage end dates
- 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
