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 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"> allowed-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"> allowed-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"> in-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"> out-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"> concurrent-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"> appropriate-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"> policy-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"> coverage-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"> unsolicited-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"> claim<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"> insurance<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"> limits<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"> network<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"> appropriate-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"> cost<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"> therapy-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"> therapy-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"> clinical-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"> duplicate-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"> contraindication<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"> guideline<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"> off-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"> business<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"> exchange<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"> processing<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"> storage<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"> ui<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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<concept>
<code value="gold-card"/>
<display value="Gold card"/>
<definition
value="Ordering Practitioner has been granted 'gold card' status with this payer/coverage type."/>
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<concept>
<code value="no-member-found"/>
<display value="Member not found"/>
<definition
value="The CRD server was unable to find a matching member, so no coverage information can be provided"/>
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<display value="Coverage not active"/>
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<display value="Authorization needed out-of-network"/>
<definition value="Authorization is necessary if out-of-network."/>
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<display value="Limitation details"/>
<definition
value="Identifies detail codes that define limitations of coverage. (Category should be 'cat-limitation')"/>
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<code value="abstract"/>
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<code value="allowed-quantity"/>
<display value="Maximum quantity"/>
<definition
value="Indicates limitations on the number of services/products allowed (possibly per time period). Value should be a Quantity"/>
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<concept>
<code value="allowed-period"/>
<display value="Maximum allowed period"/>
<definition
value="Indicates the maximum period of time that can be covered in a single order. Value should be a Period"/>
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<concept>
<code value="_decisional"/>
<display value="Decisional details"/>
<definition
value="Identifies detail codes that may impact patient and clinician decision making (Category should be 'cat-decisional')"/>
<property>
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<display value="Copay for out-of-network"/>
<definition
value="Indicates a percentage co-pay to expect if delivered out-of-network. Value should be a Quantity."/>
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<concept>
<code value="concurrent-review"/>
<display value="Concurrent review"/>
<definition
value="Additional payer-defined documentation will be required prior to claim payment. Value should be a boolean."/>
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<concept>
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<display value="Appropriate use"/>
<definition
value="Payer-defined appropriate use process must be invoked to determine coverage. Value should be a boolean."/>
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<concept>
<code value="_other"/>
<display value="Other details"/>
<definition
value="Identifies detail codes that are generally not relevant to clinicians/patients (Category should be 'cat-other')"/>
<property>
<code value="abstract"/>
<valueBoolean value="true"/>
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<concept>
<code value="policy-link"/>
<display value="Policy Link"/>
<definition
value="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."/>
</concept>
</concept>
<concept>
<code value="instructions"/>
<display value="Instructions"/>
<definition
value="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.)"/>
</concept>
<concept>
<code value="_cardType"/>
<display value="Card Type (abstract)"/>
<definition value="A collector for different profiles on CDS Hooks card"/>
<property>
<code value="abstract"/>
<valueBoolean value="true"/>
</property>
<concept>
<code value="coverage-info"/>
<display value="Coverage Information"/>
<definition
value="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 value="unsolicited-determ"/>
<display value="Unsolicited Determination"/>
<definition
value="An unsolicited approval of the service as having prior authorization requirements met without a formal submission of a prior authorization request"/>
</concept>
</concept>
<concept>
<code value="claim"/>
<display value="Claim"/>
<definition
value="Information about what steps need to be taken to submit a claim for the service"/>
</concept>
<concept>
<code value="insurance"/>
<display value="Insurance"/>
<definition
value="Allows a provider to update the patient's coverage information with additional details from the payer (e.g. expiry date, coverage extensions)"/>
</concept>
<concept>
<code value="limits"/>
<display value="Limits"/>
<definition
value="Messages warning about the patient approaching or exceeding their limits for a particular type of coverage or expiry date for coverage in general"/>
</concept>
<concept>
<code value="network"/>
<display value="Network"/>
<definition
value="Providing information about in-network providers that could deliver the order (or in-network alternatives for an order directed out-of-network)"/>
</concept>
<concept>
<code value="appropriate-use"/>
<display value="Appropriate Use"/>
<definition
value="Guidance on whether appropriate-use documentation is needed"/>
</concept>
<concept>
<code value="cost"/>
<display value="Cost"/>
<definition
value="What is the anticipated cost to the patient based on their coverage"/>
</concept>
<concept>
<code value="therapy-alternatives-opt"/>
<display value="Optional Therapy Alternatives"/>
<definition
value="Are there alternative therapies that have better coverage and/or are lower-cost for the patient"/>
</concept>
<concept>
<code value="therapy-alternatives-req"/>
<display value="Required Therapy Alternatives"/>
<definition
value="Are there alternative therapies that must be tried first prior to coverage being available for the proposed therapy"/>
</concept>
<concept>
<code value="clinical-reminder"/>
<display value="Clinical Reminder"/>
<definition
value="Reminders that a patient is due for certain screening or other therapy (based on payer recorded date of last intervention)"/>
</concept>
<concept>
<code value="duplicate-therapy"/>
<display value="Duplicate Therapy"/>
<definition
value="Notice that the proposed intervention has already recently occurred with a different provider when that information is not already available in the provider system"/>
</concept>
<concept>
<code value="contraindication"/>
<display value="Contraindication"/>
<definition
value="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"/>
</concept>
<concept>
<code value="guideline"/>
<display value="Guideline"/>
<definition
value="Indication that there is a guideline available for the proposed therapy (with an option to view)"/>
</concept>
<concept>
<code value="off-guideline"/>
<display value="Off Guideline"/>
<definition
value="Notice that the proposed therapy may be contrary to best-practice guidelines, typically with an option to view the relevant guideline"/>
</concept>
</concept>
<concept>
<code value="_reqcat"/>
<display value="Requirements Categories"/>
<definition
value="Codes that help to categorize requirements statements"/>
<property>
<code value="abstract"/>
<valueBoolean value="true"/>
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<concept>
<code value="business"/>
<display value="business"/>
<definition
value="Requirements relating to the business operations of the entities responsible for a system"/>
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<concept>
<code value="exchange"/>
<display value="exchange"/>
<definition
value="Requirements relating to when or how data is exchanged with other systems"/>
</concept>
<concept>
<code value="processing"/>
<display value="processing"/>
<definition
value="Requirements related to how data is dealt with internally to a system"/>
</concept>
<concept>
<code value="storage"/>
<display value="storage"/>
<definition
value="Requirements relating to when or how data is or is not persisted within a system"/>
</concept>
<concept>
<code value="ui"/>
<display value="ui"/>
<definition
value="Requirements relating to the appearance of information on a user interface"/>
</concept>
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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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