Consolidated CDA Release 2.2
2.2 - CI Build United States of America flag

Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.2/ and changes regularly. See the Directory of published versions

Resource Profile: Policy Activity

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.61 Version: 2.2
Active as of 2022-05-13 Computable Name: PolicyActivity
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.4.61:2015-08-01

A policy activity represents the policy or program providing the coverage. The person for whom payment is being provided (i.e., the patient) is the covered party. The subscriber of the policy or program is represented as a participant that is the holder of the coverage. The payer is represented as the performer of the policy activity.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from CDAR2.Act

Summary

Mandatory: 25 elements (14 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Act.templateId is sliced based on the values of value:root, value:extension
  • There is a slice with no discriminator at Act.code.translation
  • The element Act.performer is sliced based on the values of value:templateId, value:assignedEntity
  • The element Act.participant is sliced based on the values of value:templateId, value:participantRole, value:typeCode
  • The element Act.entryRelationship is sliced based on the value of value:typeCode

This structure is derived from CDAR2.Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.Act
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.61
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CDBinding: VSAC 2.16.840.1.113883.3.88.12.3221.5.2 (preferred)
.... Slices for translation 0..*CDSlice: Unordered, Open by
..... translation:translation1 1..*CDBinding: Payer (preferred)
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... Slices for performer 0..*Performer2This performer represents the Guarantor.
Slice: Unordered, Open by value:templateId, value:assignedEntity
.... performer:performer1 1..1Performer2This performer represents the Payer.
..... typeCode 1..1csRequired Pattern: PRF
..... templateId 1..1II
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.87
..... assignedEntity 1..1AssignedEntity
...... id 1..*II
...... code 0..1CE
....... code 1..1stringBinding: Financially Responsible Party Type Value Set (preferred)
...... addr 0..1USRealmAddressADUSFIELDED
...... telecom 0..*TEL
...... representedOrganization 0..1Organization
....... name 0..1ON
.... performer:performer2 0..*Performer2Required Pattern: PRF
..... templateId 1..1II
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.88
..... time 0..1IVL_TS
..... assignedEntity I1..1AssignedEntity1198-8967: **SHOULD** include assignedEntity/assignedPerson/name AND/OR assignedEntity/representedOrganization/name (CONF:1198-8967).
...... code 1..1CE
....... code 1..1stringRequired Pattern: GUAR
....... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.5.110
...... addr 0..1USRealmAddressADUSFIELDED
...... telecom 0..*TEL
... Slices for participant 0..*Participant2When the Subscriber is the patient, the participant element describing the subscriber *SHALL NOT* be present. This information will be recorded instead in the data elements used to record member information.
Slice: Unordered, Open by value:templateId, value:participantRole, value:typeCode
.... participant:participant1 1..1Participant2
..... typeCode 1..1codeRequired Pattern: COV
..... templateId 1..1II
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.89
..... time 0..1IVL_TS
...... low 0..1TS
...... high 0..1TS
..... participantRole 1..1ParticipantRole
...... id I1..*II1198-8984: This id is a unique identifier for the covered party member. Implementers **SHOULD** use the same GUID for each instance of a member identifier from the same health plan (CONF:1198-8984).
...... code 1..1CE
....... code 0..1stringBinding: Coverage Role Type Value Set (preferred)
...... addr I0..1AD1198-10484: The content of addr **SHALL** be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:1198-10484).
...... playingEntity 0..1PlayingEntity
​....... birthTime I1..1If the covered party?s date of birth is recorded differently in the health plan and in the registration/pharmacy benefit summary, use the date of birth as it is recorded in the health plan.
1198-31345: The prefix sdtc: **SHALL** be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the birthTime element (CONF:1198-31345).
....... name 1..*ENIf the covered party?s name is recorded differently in the health plan and in the registration/pharmacy benefit summary (due to marriage or for other reasons), use the name as it is recorded in the health plan.
.... participant:participant2 I0..1Participant21198-17139: When the Subscriber is the patient, the participant element describing the subscriber **SHALL NOT** be present. This information will be recorded instead in the data elements used to record member information (CONF:1198-17139).
..... typeCode 1..1codeRequired Pattern: HLD
..... templateId 1..1II
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.90
..... time 0..1IVL_TS
..... participantRole 1..1ParticipantRole
...... id I1..*II1198-10120: This id is a unique identifier for the subscriber of the coverage (CONF:1198-10120).
...... addr I0..1AD1198-10483: The content of addr **SHALL** be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:1198-10483).
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by value:typeCode
.... entryRelationship:entryRelationship1 I1..*Element1198-8942: The target of a policy activity with act/entryRelationship/@typeCode="REFR" **SHALL** be an authorization activity (templateId 2.16.840.1.113883.10.20.1.19) *OR* an act, with act[@classCode="ACT"] and act[@moodCode="DEF"], representing a description of the coverage plan (CONF:1198-8942).
1198-8943: A description of the coverage plan **SHALL** contain one or more act/id, to represent the plan identifier, and an act/text with the name of the plan (CONF:1198-8943).
..... typeCode 1..1codeRequired Pattern: REFR

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.Act
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... realmCode 0..*CS
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.61
..... extension 1..1stringRequired Pattern: 2015-08-01
... id 1..*IIThis id is a unique identifier for the policy or program providing the coverage
... code 1..1CDBinding: VSAC 2.16.840.1.113883.3.88.12.3221.5.2 (preferred)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 0..1string
.... codeSystem 0..1string
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... Slices for translation 0..*CDSlice: Unordered, Open by
..... translation:translation1 1..*CDBinding: Payer (preferred)
... negationInd 0..1boolean
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: completed
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... Slices for performer 0..*Performer2This performer represents the Guarantor.
Slice: Unordered, Open by value:templateId, value:assignedEntity
.... performer:performer1 1..1Performer2This performer represents the Payer.
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1csBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 1..1II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.87
...... extension 0..1string
..... functionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
..... time 0..1IVL_TS
..... modeCode 0..1CE
..... assignedEntity 1..1AssignedEntity
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... templateId 0..*II
...... id 1..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... code 1..1stringBinding: Financially Responsible Party Type Value Set (preferred)
....... codeSystem 0..1string
....... codeSystemName 0..1string
....... codeSystemVersion 0..1string
....... displayName 0..1string
....... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
....... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... addr I0..1USRealmAddressADUSFIELDED
...... telecom 0..*TEL
...... assignedPerson 0..1Person
...... representedOrganization 0..1Organization
....... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... id 0..*II
....... name 0..1ON
....... telecom 0..*TEL
....... addr 0..*AD
....... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (extensible)
....... asOrganizationPartOf 0..1OrganizationPartOf
.... performer:performer2 0..*Performer2Required Pattern: PRF
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1csBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 1..1II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.88
...... extension 0..1string
..... functionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
..... time 0..1IVL_TS
..... modeCode 0..1CE
..... assignedEntity I1..1AssignedEntity1198-8967: **SHOULD** include assignedEntity/assignedPerson/name AND/OR assignedEntity/representedOrganization/name (CONF:1198-8967).
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... templateId 0..*II
...... id 1..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 1..1CEBinding: v3 Code System RoleCode (extensible)
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... code 1..1stringRequired Pattern: GUAR
....... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.5.110
....... codeSystemName 0..1string
....... codeSystemVersion 0..1string
....... displayName 0..1string
....... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
....... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... addr I0..1USRealmAddressADUSFIELDED
...... telecom 0..*TEL
...... assignedPerson 0..1Person
...... representedOrganization 0..1Organization
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for participant 0..*Participant2When the Subscriber is the patient, the participant element describing the subscriber *SHALL NOT* be present. This information will be recorded instead in the data elements used to record member information.
Slice: Unordered, Open by value:templateId, value:participantRole, value:typeCode
.... participant:participant1 1..1Participant2
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: COV
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 1..1II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.89
...... extension 0..1string
..... sdtcFunctionCode 0..1CEXML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1dateTime
...... inclusive 0..1boolean
...... operator 0..1code
...... low 0..1TS
...... high 0..1TS
...... width 0..1PQ
...... center 0..1TS
..... awarenessCode 0..1CE
..... participantRole 1..1ParticipantRole
...... classCode 1..1codeBinding: RoleClassRoot (required)
...... templateId 0..*II
...... id I1..*II1198-8984: This id is a unique identifier for the covered party member. Implementers **SHOULD** use the same GUID for each instance of a member identifier from the same health plan (CONF:1198-8984).
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 1..1CEBinding: v3 Code System RoleCode (extensible)
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... code 0..1stringBinding: Coverage Role Type Value Set (preferred)
....... codeSystem 0..1string
....... codeSystemName 0..1string
....... codeSystemVersion 0..1string
....... displayName 0..1string
....... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
....... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... addr I0..1AD1198-10484: The content of addr **SHALL** be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:1198-10484).
...... telecom 0..*TEL
...... playingDevice 0..1Device
...... playingEntity 0..1PlayingEntity
....... classCode 1..1codeBinding: EntityClassRoot (required)
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... code 0..1CEBinding: EntityCode (extensible)
....... quantity 0..*PQ
....... name 1..*ENIf the covered party?s name is recorded differently in the health plan and in the registration/pharmacy benefit summary (due to marriage or for other reasons), use the name as it is recorded in the health plan.
....... desc 0..1ED
...... scopingEntity 0..1Entity
.... participant:participant2 I0..1Participant21198-17139: When the Subscriber is the patient, the participant element describing the subscriber **SHALL NOT** be present. This information will be recorded instead in the data elements used to record member information (CONF:1198-17139).
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: HLD
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 1..1II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.90
...... extension 0..1string
..... sdtcFunctionCode 0..1CEXML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
..... awarenessCode 0..1CE
..... participantRole 1..1ParticipantRole
...... classCode 1..1codeBinding: RoleClassRoot (required)
...... templateId 0..*II
...... id I1..*II1198-10120: This id is a unique identifier for the subscriber of the coverage (CONF:1198-10120).
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... addr I0..1AD1198-10483: The content of addr **SHALL** be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:1198-10483).
...... telecom 0..*TEL
...... playingDevice 0..1Device
...... playingEntity 0..1PlayingEntity
...... scopingEntity 0..1Entity
... Slices for entryRelationship I0..*ElementSlice: Unordered, Open by value:typeCode
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:entryRelationship1 I1..*Element1198-8942: The target of a policy activity with act/entryRelationship/@typeCode="REFR" **SHALL** be an authorization activity (templateId 2.16.840.1.113883.10.20.1.19) *OR* an act, with act[@classCode="ACT"] and act[@moodCode="DEF"], representing a description of the coverage plan (CONF:1198-8942).
1198-8943: A description of the coverage plan **SHALL** contain one or more act/id, to represent the plan identifier, and an act/text with the name of the plan (CONF:1198-8943).
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

This structure is derived from CDAR2.Act

Summary

Mandatory: 25 elements (14 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Act.templateId is sliced based on the values of value:root, value:extension
  • There is a slice with no discriminator at Act.code.translation
  • The element Act.performer is sliced based on the values of value:templateId, value:assignedEntity
  • The element Act.participant is sliced based on the values of value:templateId, value:participantRole, value:typeCode
  • The element Act.entryRelationship is sliced based on the value of value:typeCode

Differential View

This structure is derived from CDAR2.Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.Act
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.61
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CDBinding: VSAC 2.16.840.1.113883.3.88.12.3221.5.2 (preferred)
.... Slices for translation 0..*CDSlice: Unordered, Open by
..... translation:translation1 1..*CDBinding: Payer (preferred)
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... Slices for performer 0..*Performer2This performer represents the Guarantor.
Slice: Unordered, Open by value:templateId, value:assignedEntity
.... performer:performer1 1..1Performer2This performer represents the Payer.
..... typeCode 1..1csRequired Pattern: PRF
..... templateId 1..1II
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.87
..... assignedEntity 1..1AssignedEntity
...... id 1..*II
...... code 0..1CE
....... code 1..1stringBinding: Financially Responsible Party Type Value Set (preferred)
...... addr 0..1USRealmAddressADUSFIELDED
...... telecom 0..*TEL
...... representedOrganization 0..1Organization
....... name 0..1ON
.... performer:performer2 0..*Performer2Required Pattern: PRF
..... templateId 1..1II
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.88
..... time 0..1IVL_TS
..... assignedEntity I1..1AssignedEntity1198-8967: **SHOULD** include assignedEntity/assignedPerson/name AND/OR assignedEntity/representedOrganization/name (CONF:1198-8967).
...... code 1..1CE
....... code 1..1stringRequired Pattern: GUAR
....... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.5.110
...... addr 0..1USRealmAddressADUSFIELDED
...... telecom 0..*TEL
... Slices for participant 0..*Participant2When the Subscriber is the patient, the participant element describing the subscriber *SHALL NOT* be present. This information will be recorded instead in the data elements used to record member information.
Slice: Unordered, Open by value:templateId, value:participantRole, value:typeCode
.... participant:participant1 1..1Participant2
..... typeCode 1..1codeRequired Pattern: COV
..... templateId 1..1II
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.89
..... time 0..1IVL_TS
...... low 0..1TS
...... high 0..1TS
..... participantRole 1..1ParticipantRole
...... id I1..*II1198-8984: This id is a unique identifier for the covered party member. Implementers **SHOULD** use the same GUID for each instance of a member identifier from the same health plan (CONF:1198-8984).
...... code 1..1CE
....... code 0..1stringBinding: Coverage Role Type Value Set (preferred)
...... addr I0..1AD1198-10484: The content of addr **SHALL** be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:1198-10484).
...... playingEntity 0..1PlayingEntity
​....... birthTime I1..1If the covered party?s date of birth is recorded differently in the health plan and in the registration/pharmacy benefit summary, use the date of birth as it is recorded in the health plan.
1198-31345: The prefix sdtc: **SHALL** be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the birthTime element (CONF:1198-31345).
....... name 1..*ENIf the covered party?s name is recorded differently in the health plan and in the registration/pharmacy benefit summary (due to marriage or for other reasons), use the name as it is recorded in the health plan.
.... participant:participant2 I0..1Participant21198-17139: When the Subscriber is the patient, the participant element describing the subscriber **SHALL NOT** be present. This information will be recorded instead in the data elements used to record member information (CONF:1198-17139).
..... typeCode 1..1codeRequired Pattern: HLD
..... templateId 1..1II
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.90
..... time 0..1IVL_TS
..... participantRole 1..1ParticipantRole
...... id I1..*II1198-10120: This id is a unique identifier for the subscriber of the coverage (CONF:1198-10120).
...... addr I0..1AD1198-10483: The content of addr **SHALL** be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:1198-10483).
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by value:typeCode
.... entryRelationship:entryRelationship1 I1..*Element1198-8942: The target of a policy activity with act/entryRelationship/@typeCode="REFR" **SHALL** be an authorization activity (templateId 2.16.840.1.113883.10.20.1.19) *OR* an act, with act[@classCode="ACT"] and act[@moodCode="DEF"], representing a description of the coverage plan (CONF:1198-8942).
1198-8943: A description of the coverage plan **SHALL** contain one or more act/id, to represent the plan identifier, and an act/text with the name of the plan (CONF:1198-8943).
..... typeCode 1..1codeRequired Pattern: REFR

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.Act
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... realmCode 0..*CS
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.61
..... extension 1..1stringRequired Pattern: 2015-08-01
... id 1..*IIThis id is a unique identifier for the policy or program providing the coverage
... code 1..1CDBinding: VSAC 2.16.840.1.113883.3.88.12.3221.5.2 (preferred)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 0..1string
.... codeSystem 0..1string
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... Slices for translation 0..*CDSlice: Unordered, Open by
..... translation:translation1 1..*CDBinding: Payer (preferred)
... negationInd 0..1boolean
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: completed
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... Slices for performer 0..*Performer2This performer represents the Guarantor.
Slice: Unordered, Open by value:templateId, value:assignedEntity
.... performer:performer1 1..1Performer2This performer represents the Payer.
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1csBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 1..1II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.87
...... extension 0..1string
..... functionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
..... time 0..1IVL_TS
..... modeCode 0..1CE
..... assignedEntity 1..1AssignedEntity
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... templateId 0..*II
...... id 1..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... code 1..1stringBinding: Financially Responsible Party Type Value Set (preferred)
....... codeSystem 0..1string
....... codeSystemName 0..1string
....... codeSystemVersion 0..1string
....... displayName 0..1string
....... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
....... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... addr I0..1USRealmAddressADUSFIELDED
...... telecom 0..*TEL
...... assignedPerson 0..1Person
...... representedOrganization 0..1Organization
....... classCode 1..1codeBinding: EntityClassOrganization (required)
Fixed Value: ORG
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... id 0..*II
....... name 0..1ON
....... telecom 0..*TEL
....... addr 0..*AD
....... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (extensible)
....... asOrganizationPartOf 0..1OrganizationPartOf
.... performer:performer2 0..*Performer2Required Pattern: PRF
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 0..1csBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 1..1II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.88
...... extension 0..1string
..... functionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
..... time 0..1IVL_TS
..... modeCode 0..1CE
..... assignedEntity I1..1AssignedEntity1198-8967: **SHOULD** include assignedEntity/assignedPerson/name AND/OR assignedEntity/representedOrganization/name (CONF:1198-8967).
...... classCode 1..1codeBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... templateId 0..*II
...... id 1..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 1..1CEBinding: v3 Code System RoleCode (extensible)
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... code 1..1stringRequired Pattern: GUAR
....... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.5.110
....... codeSystemName 0..1string
....... codeSystemVersion 0..1string
....... displayName 0..1string
....... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
....... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... addr I0..1USRealmAddressADUSFIELDED
...... telecom 0..*TEL
...... assignedPerson 0..1Person
...... representedOrganization 0..1Organization
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for participant 0..*Participant2When the Subscriber is the patient, the participant element describing the subscriber *SHALL NOT* be present. This information will be recorded instead in the data elements used to record member information.
Slice: Unordered, Open by value:templateId, value:participantRole, value:typeCode
.... participant:participant1 1..1Participant2
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: COV
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 1..1II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.89
...... extension 0..1string
..... sdtcFunctionCode 0..1CEXML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... value 0..1dateTime
...... inclusive 0..1boolean
...... operator 0..1code
...... low 0..1TS
...... high 0..1TS
...... width 0..1PQ
...... center 0..1TS
..... awarenessCode 0..1CE
..... participantRole 1..1ParticipantRole
...... classCode 1..1codeBinding: RoleClassRoot (required)
...... templateId 0..*II
...... id I1..*II1198-8984: This id is a unique identifier for the covered party member. Implementers **SHOULD** use the same GUID for each instance of a member identifier from the same health plan (CONF:1198-8984).
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 1..1CEBinding: v3 Code System RoleCode (extensible)
....... nullFlavor 0..1codeBinding: NullFlavor (required)
....... code 0..1stringBinding: Coverage Role Type Value Set (preferred)
....... codeSystem 0..1string
....... codeSystemName 0..1string
....... codeSystemVersion 0..1string
....... displayName 0..1string
....... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
....... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1ED
....... translation 0..*CD
...... addr I0..1AD1198-10484: The content of addr **SHALL** be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:1198-10484).
...... telecom 0..*TEL
...... playingDevice 0..1Device
...... playingEntity 0..1PlayingEntity
....... classCode 1..1codeBinding: EntityClassRoot (required)
....... determinerCode 1..1codeBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... code 0..1CEBinding: EntityCode (extensible)
....... quantity 0..*PQ
....... name 1..*ENIf the covered party?s name is recorded differently in the health plan and in the registration/pharmacy benefit summary (due to marriage or for other reasons), use the name as it is recorded in the health plan.
....... desc 0..1ED
...... scopingEntity 0..1Entity
.... participant:participant2 I0..1Participant21198-17139: When the Subscriber is the patient, the participant element describing the subscriber **SHALL NOT** be present. This information will be recorded instead in the data elements used to record member information (CONF:1198-17139).
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: HLD
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 1..1II
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... assigningAuthorityName 0..1string
...... displayable 0..1boolean
...... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.90
...... extension 0..1string
..... sdtcFunctionCode 0..1CEXML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
..... awarenessCode 0..1CE
..... participantRole 1..1ParticipantRole
...... classCode 1..1codeBinding: RoleClassRoot (required)
...... templateId 0..*II
...... id I1..*II1198-10120: This id is a unique identifier for the subscriber of the coverage (CONF:1198-10120).
...... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... addr I0..1AD1198-10483: The content of addr **SHALL** be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:1198-10483).
...... telecom 0..*TEL
...... playingDevice 0..1Device
...... playingEntity 0..1PlayingEntity
...... scopingEntity 0..1Entity
... Slices for entryRelationship I0..*ElementSlice: Unordered, Open by value:typeCode
.... entryRelationship:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:entryRelationship1 I1..*Element1198-8942: The target of a policy activity with act/entryRelationship/@typeCode="REFR" **SHALL** be an authorization activity (templateId 2.16.840.1.113883.10.20.1.19) *OR* an act, with act[@classCode="ACT"] and act[@moodCode="DEF"], representing a description of the coverage plan (CONF:1198-8942).
1198-8943: A description of the coverage plan **SHALL** contain one or more act/id, to represent the plan identifier, and an act/text with the name of the plan (CONF:1198-8943).
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
Act.templateId:primary.nullFlavorrequiredNullFlavor
Act.codepreferredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.5.2
Act.code.nullFlavorrequiredNullFlavor
Act.code.translation:translation1preferredPayer
Act.statusCoderequiredActStatus
Act.statusCode.nullFlavorrequiredNullFlavor
Act.priorityCodeextensibleActPriority
Act.languageCoderequiredHumanLanguage
Act.subject.typeCoderequiredFixed Value: SBJ
Act.subject.contextControlCoderequiredFixed Value: OP
Act.subject.awarenessCodeextensibleTargetAwareness
Act.performer:performer1.nullFlavorrequiredNullFlavor
Act.performer:performer1.typeCoderequiredFixed Value: PRF
Act.performer:performer1.templateId.nullFlavorrequiredNullFlavor
Act.performer:performer1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
Act.performer:performer1.assignedEntity.codeextensibleRoleCode
Act.performer:performer1.assignedEntity.code.nullFlavorrequiredNullFlavor
Act.performer:performer1.assignedEntity.code.codepreferredFinanciallyResponsiblePartyTypeValueSet
Act.performer:performer1.assignedEntity.representedOrganization.classCoderequiredFixed Value: ORG
Act.performer:performer1.assignedEntity.representedOrganization.determinerCoderequiredFixed Value: INSTANCE
Act.performer:performer1.assignedEntity.representedOrganization.standardIndustryClassCodeextensibleOrganizationIndustryClassNAICS
Act.performer:performer2.nullFlavorrequiredNullFlavor
Act.performer:performer2.typeCoderequiredFixed Value: PRF
Act.performer:performer2.templateId.nullFlavorrequiredNullFlavor
Act.performer:performer2.assignedEntity.classCoderequiredFixed Value: ASSIGNED
Act.performer:performer2.assignedEntity.codeextensibleRoleCode
Act.performer:performer2.assignedEntity.code.nullFlavorrequiredNullFlavor
Act.informant.typeCoderequiredFixed Value: INF
Act.informant.contextControlCoderequiredFixed Value: OP
Act.participant:participant1.nullFlavorrequiredNullFlavor
Act.participant:participant1.typeCoderequiredPattern: COV
Act.participant:participant1.contextControlCoderequiredFixed Value: OP
Act.participant:participant1.templateId.nullFlavorrequiredNullFlavor
Act.participant:participant1.time.nullFlavorrequiredNullFlavor
Act.participant:participant1.participantRole.classCoderequiredRoleClassRoot
Act.participant:participant1.participantRole.codeextensibleRoleCode
Act.participant:participant1.participantRole.code.nullFlavorrequiredNullFlavor
Act.participant:participant1.participantRole.code.codepreferredCoverage Role Type Value Set
Act.participant:participant1.participantRole.playingEntity.classCoderequiredEntityClassRoot
Act.participant:participant1.participantRole.playingEntity.determinerCoderequiredFixed Value: INSTANCE
Act.participant:participant1.participantRole.playingEntity.codeextensibleEntityCode
Act.participant:participant2.nullFlavorrequiredNullFlavor
Act.participant:participant2.typeCoderequiredPattern: HLD
Act.participant:participant2.contextControlCoderequiredFixed Value: OP
Act.participant:participant2.templateId.nullFlavorrequiredNullFlavor
Act.participant:participant2.participantRole.classCoderequiredRoleClassRoot
Act.participant:participant2.participantRole.codeextensibleRoleCode

Constraints

IdGradePathDetailsRequirements
81-7296errorAct.performer:performer1.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
1198-8967warningAct.performer:performer2.assignedEntity**SHOULD** include assignedEntity/assignedPerson/name AND/OR assignedEntity/representedOrganization/name (CONF:1198-8967).
:
81-7296errorAct.performer:performer2.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
1198-8984warningAct.participant:participant1.participantRole.idThis id is a unique identifier for the covered party member. Implementers **SHOULD** use the same GUID for each instance of a member identifier from the same health plan (CONF:1198-8984).
:
1198-10484errorAct.participant:participant1.participantRole.addrThe content of addr **SHALL** be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:1198-10484).
:
1198-17139warningAct.participant:participant2When the Subscriber is the patient, the participant element describing the subscriber **SHALL NOT** be present. This information will be recorded instead in the data elements used to record member information (CONF:1198-17139).
:
1198-10120warningAct.participant:participant2.participantRole.idThis id is a unique identifier for the subscriber of the coverage (CONF:1198-10120).
:
1198-10483errorAct.participant:participant2.participantRole.addrThe content of addr **SHALL** be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:1198-10483).
:
act-er-1errorAct.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
act-er-1errorAct.entryRelationship:entryRelationship1Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
1198-8942warningAct.entryRelationship:entryRelationship1The target of a policy activity with act/entryRelationship/@typeCode="REFR" **SHALL** be an authorization activity (templateId 2.16.840.1.113883.10.20.1.19) *OR* an act, with act[@classCode="ACT"] and act[@moodCode="DEF"], representing a description of the coverage plan (CONF:1198-8942).
:
1198-8943warningAct.entryRelationship:entryRelationship1A description of the coverage plan **SHALL** contain one or more act/id, to represent the plan identifier, and an act/text with the name of the plan (CONF:1198-8943).
: