Da Vinci - Coverage Requirements Discovery
2.2.0-snapshot - STU 2.2 Peer Review
Da Vinci - Coverage Requirements Discovery
2.2.0-snapshot - STU 2.2 Peer Review
Da Vinci - Coverage Requirements Discovery, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.2.0-snapshot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-crd/ and changes regularly. See the Directory of published versions
| Page standards status: Trial-use | Maturity Level: 4 |
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"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CodeSystem temp</b></p><a name=\"temp\"> </a><a name=\"hctemp\"> </a><p><b>Properties</b></p><p><b>This code system defines the following properties for its concepts</b></p><table class=\"grid\"><tr><td><b>Name</b></td><td><b>Code</b></td><td><b>URI</b></td><td><b>Type</b></td></tr><tr><td>Not Selectable</td><td>abstract</td><td>http://hl7.org/fhir/concept-properties#notSelectable</td><td>boolean</td></tr></table><p><b>Concepts</b></p><p>This case-sensitive code system <code>http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp</code> defines the following codes in a Is-A hierarchy:</p><table class=\"codes\"><tr><td><b>Lvl</b></td><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td><td><b>Not Selectable</b></td></tr><tr><td>1</td><td style=\"white-space:nowrap\">gold-card<a name=\"temp-gold-card\"> </a></td><td>Gold card</td><td>Ordering Practitioner has been granted 'gold card' status with this payer/coverage type.</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">no-member-found<a name=\"temp-no-member-found\"> </a></td><td>Member not found</td><td>The CRD server was unable to find a matching member, so no coverage information can be provided</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">no-active-coverage<a name=\"temp-no-active-coverage\"> </a></td><td>Coverage not active</td><td>The referenced insurance coverage for the member is not active, so no coverage information can be provided</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">auth-out-network<a name=\"temp-auth-out-network\"> </a></td><td>Authorization needed out-of-network</td><td>Authorization is necessary if out-of-network.</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">_limitation<a name=\"temp-_limitation\"> </a></td><td>Limitation details</td><td>Identifies detail codes that define limitations of coverage. (Category should be 'cat-limitation')</td><td>true</td></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0allowed-quantity<a name=\"temp-allowed-quantity\"> </a></td><td>Maximum quantity</td><td>Indicates limitations on the number of services/products allowed (possibly per time period). Value should be a Quantity</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0allowed-period<a name=\"temp-allowed-period\"> </a></td><td>Maximum allowed period</td><td>Indicates the maximum period of time that can be covered in a single order. Value should be a Period</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">_decisional<a name=\"temp-_decisional\"> </a></td><td>Decisional details</td><td>Identifies detail codes that may impact patient and clinician decision making (Category should be 'cat-decisional')</td><td>true</td></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0in-network-copay<a name=\"temp-in-network-copay\"> </a></td><td>Copay for in-network</td><td>Indicates a percentage co-pay to expect if delivered in-network. Value should be a Quantity.</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0out-network-copay<a name=\"temp-out-network-copay\"> </a></td><td>Copay for out-of-network</td><td>Indicates a percentage co-pay to expect if delivered out-of-network. Value should be a Quantity.</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0concurrent-review<a name=\"temp-concurrent-review\"> </a></td><td>Concurrent review</td><td>Additional payer-defined documentation will be required prior to claim payment. Value should be a boolean.</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0appropriate-use-needed<a name=\"temp-appropriate-use-needed\"> </a></td><td>Appropriate use</td><td>Payer-defined appropriate use process must be invoked to determine coverage. Value should be a boolean.</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">_other<a name=\"temp-_other\"> </a></td><td>Other details</td><td>Identifies detail codes that are generally not relevant to clinicians/patients (Category should be 'cat-other')</td><td>true</td></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0policy-link<a name=\"temp-policy-link\"> </a></td><td>Policy Link</td><td>A URL pointing to the specific portion of a payer policy, coverage agreement or similar authoritative document that provides a portion of the basis for the decision documented in the coverage-information. Value should be a url.</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">instructions<a name=\"temp-instructions\"> </a></td><td>Instructions</td><td>Information to display to the user that gives guidance about what steps to take in achieving the recommended actions identified by this coverage-information (e.g. special instructions about requesting authorization, details about information needed, details about data retention, etc.). Value should be a string. (Category may vary.)</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">_cardType<a name=\"temp-_cardType\"> </a></td><td>Card Type (abstract)</td><td>A collector for different profiles on CDS Hooks card</td><td>true</td></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0coverage-info<a name=\"temp-coverage-info\"> </a></td><td>Coverage Information</td><td>Information related to the patient's coverage, including whether a service is covered, requires prior authorization, is approved without seeking prior authorization, and/or requires additional documentation or data collection</td><td/></tr><tr><td>3</td><td style=\"white-space:nowrap\">\u00a0\u00a0\u00a0\u00a0unsolicited-determ<a name=\"temp-unsolicited-determ\"> </a></td><td>Unsolicited Determination</td><td>An unsolicited approval of the service as having prior authorization requirements met without a formal submission of a prior authorization request</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0claim<a name=\"temp-claim\"> </a></td><td>Claim</td><td>Information about what steps need to be taken to submit a claim for the service</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0insurance<a name=\"temp-insurance\"> </a></td><td>Insurance</td><td>Allows a provider to update the patient's coverage information with additional details from the payer (e.g. expiry date, coverage extensions)</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0limits<a name=\"temp-limits\"> </a></td><td>Limits</td><td>Messages warning about the patient approaching or exceeding their limits for a particular type of coverage or expiry date for coverage in general</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0network<a name=\"temp-network\"> </a></td><td>Network</td><td>Providing information about in-network providers that could deliver the order (or in-network alternatives for an order directed out-of-network)</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0appropriate-use<a name=\"temp-appropriate-use\"> </a></td><td>Appropriate Use</td><td>Guidance on whether appropriate-use documentation is needed</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0cost<a name=\"temp-cost\"> </a></td><td>Cost</td><td>What is the anticipated cost to the patient based on their coverage</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0therapy-alternatives-opt<a name=\"temp-therapy-alternatives-opt\"> </a></td><td>Optional Therapy Alternatives</td><td>Are there alternative therapies that have better coverage and/or are lower-cost for the patient</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0therapy-alternatives-req<a name=\"temp-therapy-alternatives-req\"> </a></td><td>Required Therapy Alternatives</td><td>Are there alternative therapies that must be tried first prior to coverage being available for the proposed therapy</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0clinical-reminder<a name=\"temp-clinical-reminder\"> </a></td><td>Clinical Reminder</td><td>Reminders that a patient is due for certain screening or other therapy (based on payer recorded date of last intervention)</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0duplicate-therapy<a name=\"temp-duplicate-therapy\"> </a></td><td>Duplicate Therapy</td><td>Notice that the proposed intervention has already recently occurred with a different provider when that information is not already available in the provider system</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0contraindication<a name=\"temp-contraindication\"> </a></td><td>Contraindication</td><td>Notice that the proposed intervention may be contraindicated based on information the payer has in their record that the provider does not have in theirs</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0guideline<a name=\"temp-guideline\"> </a></td><td>Guideline</td><td>Indication that there is a guideline available for the proposed therapy (with an option to view)</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0off-guideline<a name=\"temp-off-guideline\"> </a></td><td>Off Guideline</td><td>Notice that the proposed therapy may be contrary to best-practice guidelines, typically with an option to view the relevant guideline</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">_reqcat<a name=\"temp-_reqcat\"> </a></td><td>Requirements Categories</td><td>Codes that help to categorize requirements statements</td><td>true</td></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0business<a name=\"temp-business\"> </a></td><td>business</td><td>Requirements relating to the business operations of the entities responsible for a system</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0exchange<a name=\"temp-exchange\"> </a></td><td>exchange</td><td>Requirements relating to when or how data is exchanged with other systems</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0processing<a name=\"temp-processing\"> </a></td><td>processing</td><td>Requirements related to how data is dealt with internally to a system</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0storage<a name=\"temp-storage\"> </a></td><td>storage</td><td>Requirements relating to when or how data is or is not persisted within a system</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">\u00a0\u00a0ui<a name=\"temp-ui\"> </a></td><td>ui</td><td>Requirements relating to the appearance of information on a user interface</td><td/></tr></table></div>"
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"url" : "http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp",
"identifier" : [
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"system" : "urn:ietf:rfc:3986",
"value" : "urn:oid:2.16.840.1.113883.4.642.40.18.16.1"
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"version" : "2.2.0-snapshot",
"name" : "CRDTempCodes",
"title" : "CRD Temporary Codes",
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"date" : "2026-01-30T22:02:38+00:00",
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"description" : "Codes temporarily defined as part of the CRD implementation guide. These will eventually migrate into an officially maintained terminology (likely either SNOMED CT or HL7's UTG code systems).",
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],
"concept" : [
{
"code" : "gold-card",
"display" : "Gold card",
"definition" : "Ordering Practitioner has been granted 'gold card' status with this payer/coverage type."
},
{
"code" : "no-member-found",
"display" : "Member not found",
"definition" : "The CRD server was unable to find a matching member, so no coverage information can be provided"
},
{
"code" : "no-active-coverage",
"display" : "Coverage not active",
"definition" : "The referenced insurance coverage for the member is not active, so no coverage information can be provided"
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{
"code" : "auth-out-network",
"display" : "Authorization needed out-of-network",
"definition" : "Authorization is necessary if out-of-network."
},
{
"code" : "_limitation",
"display" : "Limitation details",
"definition" : "Identifies detail codes that define limitations of coverage. (Category should be 'cat-limitation')",
"property" : [
{
"code" : "abstract",
"valueBoolean" : true
}
],
"concept" : [
{
"code" : "allowed-quantity",
"display" : "Maximum quantity",
"definition" : "Indicates limitations on the number of services/products allowed (possibly per time period). Value should be a Quantity"
},
{
"code" : "allowed-period",
"display" : "Maximum allowed period",
"definition" : "Indicates the maximum period of time that can be covered in a single order. Value should be a Period"
}
]
},
{
"code" : "_decisional",
"display" : "Decisional details",
"definition" : "Identifies detail codes that may impact patient and clinician decision making (Category should be 'cat-decisional')",
"property" : [
{
"code" : "abstract",
"valueBoolean" : true
}
],
"concept" : [
{
"code" : "in-network-copay",
"display" : "Copay for in-network",
"definition" : "Indicates a percentage co-pay to expect if delivered in-network. Value should be a Quantity."
},
{
"code" : "out-network-copay",
"display" : "Copay for out-of-network",
"definition" : "Indicates a percentage co-pay to expect if delivered out-of-network. Value should be a Quantity."
},
{
"code" : "concurrent-review",
"display" : "Concurrent review",
"definition" : "Additional payer-defined documentation will be required prior to claim payment. Value should be a boolean."
},
{
"code" : "appropriate-use-needed",
"display" : "Appropriate use",
"definition" : "Payer-defined appropriate use process must be invoked to determine coverage. Value should be a boolean."
}
]
},
{
"code" : "_other",
"display" : "Other details",
"definition" : "Identifies detail codes that are generally not relevant to clinicians/patients (Category should be 'cat-other')",
"property" : [
{
"code" : "abstract",
"valueBoolean" : true
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],
"concept" : [
{
"code" : "policy-link",
"display" : "Policy Link",
"definition" : "A URL pointing to the specific portion of a payer policy, coverage agreement or similar authoritative document that provides a portion of the basis for the decision documented in the coverage-information. Value should be a url."
}
]
},
{
"code" : "instructions",
"display" : "Instructions",
"definition" : "Information to display to the user that gives guidance about what steps to take in achieving the recommended actions identified by this coverage-information (e.g. special instructions about requesting authorization, details about information needed, details about data retention, etc.). Value should be a string. (Category may vary.)"
},
{
"code" : "_cardType",
"display" : "Card Type (abstract)",
"definition" : "A collector for different profiles on CDS Hooks card",
"property" : [
{
"code" : "abstract",
"valueBoolean" : true
}
],
"concept" : [
{
"code" : "coverage-info",
"display" : "Coverage Information",
"definition" : "Information related to the patient's coverage, including whether a service is covered, requires prior authorization, is approved without seeking prior authorization, and/or requires additional documentation or data collection",
"concept" : [
{
"code" : "unsolicited-determ",
"display" : "Unsolicited Determination",
"definition" : "An unsolicited approval of the service as having prior authorization requirements met without a formal submission of a prior authorization request"
}
]
},
{
"code" : "claim",
"display" : "Claim",
"definition" : "Information about what steps need to be taken to submit a claim for the service"
},
{
"code" : "insurance",
"display" : "Insurance",
"definition" : "Allows a provider to update the patient's coverage information with additional details from the payer (e.g. expiry date, coverage extensions)"
},
{
"code" : "limits",
"display" : "Limits",
"definition" : "Messages warning about the patient approaching or exceeding their limits for a particular type of coverage or expiry date for coverage in general"
},
{
"code" : "network",
"display" : "Network",
"definition" : "Providing information about in-network providers that could deliver the order (or in-network alternatives for an order directed out-of-network)"
},
{
"code" : "appropriate-use",
"display" : "Appropriate Use",
"definition" : "Guidance on whether appropriate-use documentation is needed"
},
{
"code" : "cost",
"display" : "Cost",
"definition" : "What is the anticipated cost to the patient based on their coverage"
},
{
"code" : "therapy-alternatives-opt",
"display" : "Optional Therapy Alternatives",
"definition" : "Are there alternative therapies that have better coverage and/or are lower-cost for the patient"
},
{
"code" : "therapy-alternatives-req",
"display" : "Required Therapy Alternatives",
"definition" : "Are there alternative therapies that must be tried first prior to coverage being available for the proposed therapy"
},
{
"code" : "clinical-reminder",
"display" : "Clinical Reminder",
"definition" : "Reminders that a patient is due for certain screening or other therapy (based on payer recorded date of last intervention)"
},
{
"code" : "duplicate-therapy",
"display" : "Duplicate Therapy",
"definition" : "Notice that the proposed intervention has already recently occurred with a different provider when that information is not already available in the provider system"
},
{
"code" : "contraindication",
"display" : "Contraindication",
"definition" : "Notice that the proposed intervention may be contraindicated based on information the payer has in their record that the provider does not have in theirs"
},
{
"code" : "guideline",
"display" : "Guideline",
"definition" : "Indication that there is a guideline available for the proposed therapy (with an option to view)"
},
{
"code" : "off-guideline",
"display" : "Off Guideline",
"definition" : "Notice that the proposed therapy may be contrary to best-practice guidelines, typically with an option to view the relevant guideline"
}
]
},
{
"code" : "_reqcat",
"display" : "Requirements Categories",
"definition" : "Codes that help to categorize requirements statements",
"property" : [
{
"code" : "abstract",
"valueBoolean" : true
}
],
"concept" : [
{
"code" : "business",
"display" : "business",
"definition" : "Requirements relating to the business operations of the entities responsible for a system"
},
{
"code" : "exchange",
"display" : "exchange",
"definition" : "Requirements relating to when or how data is exchanged with other systems"
},
{
"code" : "processing",
"display" : "processing",
"definition" : "Requirements related to how data is dealt with internally to a system"
},
{
"code" : "storage",
"display" : "storage",
"definition" : "Requirements relating to when or how data is or is not persisted within a system"
},
{
"code" : "ui",
"display" : "ui",
"definition" : "Requirements relating to the appearance of information on a user interface"
}
]
}
]
}
IG © 2019+ HL7 International / Financial Management.
Package hl7.fhir.us.davinci-crd#2.2.0-snapshot based on FHIR 4.0.1.
Generated
2026-01-30
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