Da Vinci Health Record Exchange (HRex)
1.1.0 - STU 1.1 United States of America flag

Da Vinci Health Record Exchange (HRex), published by HL7 International / Clinical Interoperability Council. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-ehrx/ and changes regularly. See the Directory of published versions

Resource Profile: HRex Member Match Coverage Profile

Official URL: http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage Version: 1.1.0
Standards status: Trial-use Maturity Level: 2 Computable Name: HRexCoverage
Other Identifiers: OID:2.16.840.1.113883.4.642.40.19.42.7

The HRex Coverage Profile defines the constraints for representing a member's healthcare insurance information to the Payer for member match purposes. Coverage instances complying with this profile, sometimes together with the Patient which this profile references via beneficiary, allows a payer to identify a member in their system. It aligns with the equivalent US Core profile, but diverges in that it does not require Patient.identifier for the beneficiary.

In most cases, Da Vinci will use the US Core Coverage profile when communicating Coverage.

This profile is intended for use ONLY during the $member-match operation. It differs from the US Core profile in that the referenced 'Patient' resource does not need to have an identifier (as when calling $member-match, no identifier will be known).

Usage:

Formal Views of Profile Content

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

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C 0..* Coverage Insurance or medical plan or a payment agreement
us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
... Slices for identifier S 0..* Identifier Member ID and other identifiers
Slice: Unordered, Open by value:type
.... identifier:memberid SC 0..1 Identifier Member ID
..... type 1..1 CodeableConcept Member Number identifier type
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MB
..... value S 1..1 string The value that is unique
... status S 1..1 code active | cancelled | draft | entered-in-error
... type S 0..1 CodeableConcept Coverage category such as medical or accident
Binding: Payer Type . (extensible): US Public Health Data Consortium Source of Payment Codes

... subscriberId SC 0..1 string Subscriber ID
... beneficiary S 1..1 Reference(HRex Member Match Patient) Plan beneficiary
... dependent S 0..1 string Dependent number
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: HRex Coverage Relationship ValueSet (required)
... period S 0..1 Period Coverage start and end dates
... payor S 1..1 Reference(HRex Organization Profile) Issuer of the policy
... Slices for class 0..* BackboneElement Additional coverage classifications
Slice: Unordered, Open by value:type
.... class:group S 0..1 BackboneElement Group
..... type S 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: group
..... value S 1..1 string Group Number
.... class:plan S 0..1 BackboneElement Plan
..... type S 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: plan
..... value S 1..1 string Plan Number
..... name S 0..1 string Plan Name

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationshiprequiredHRexCoverageRelationship
http://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationship
from this IG

Constraints

IdGradePath(s)DetailsRequirements
us-core-15errorCoverageMember Id in Coverage.identifier or Coverage.subscriberId SHALL be present
: identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

 

Other representations of profile: CSV, Excel, Schematron

Notes:

If the member identifier (conveyed in Coverage.identifier) is known, it must be sent as this uniquely identifies a covered individual. If not, then the Coverage.subscriberId can be used together with demographic information found by resolving Coverage.beneficiary to identify the member. (There can be multiple members associated with a single subscriber - e.g. family members of an individual who is covered under a work-based policy.)

Additional notes and guidance around how to map real-world insurance card information into the Coverage resource can be found in the CARIN Digital Insurance Card IG. As a rule, all elements available SHOULD be populated, even if not all might be strictly necessary to identify the member because rules can vary from insurer to insurer about which pieces of information are necessary to uniquely identify a member.