Generated Narrative: StructureDefinition PolicyActivity Name Flags Card. Type Description & Constraints Act <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( should-text-ref-value, 4537-17139 )">C 1..1 Act XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value, 4537-17139 #xD; Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension #xD; templateId:policy-activity 1..1 II #xD; @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.61 #xD; @extension 1..1 st Required Pattern: 2024-05-01 #xD; @classCode 1..1 cs Fixed Value: ACT #xD; @moodCode 1..1 cs Fixed Value: EVN #xD; id 1..* II 헨?헦?헖?헗?헜?: Group Identifier: This is the identifier (sent in the @extension attribute) used to uniquely refer to a specific health insurance plan. #xD; code 1..1 CD 헨?헦?헖?헗?헜?: Coverage Type: Records the category of health care payers, insurance products, or benefits. Binding: Payer Type (preferred) #xD; text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry #xD; reference <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( value-starts-octothorpe )">C 0..1 TEL Constraints: value-starts-octothorpe #xD; statusCode 1..1 CS #xD; @code 1..1 cs Fixed Value: completed #xD; Slices for performer 1..* Performer2 Slice: Unordered, Open by value:templateId.root #xD; performer:payer 1..1 Performer2 This performer represents the Payer. #xD; templateId 1..1 II #xD; @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.87 #xD; @extension 0..0 #xD; @typeCode 1..1 cs #xD; assignedEntity <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( should-code, should-representedOrganization )">C 1..1 AssignedEntity Constraints: should-code, should-representedOrganization #xD; id 1..* II 헨?헦?헖?헗?헜?: Payer Identifier: This is the Payer id. The root is a unique identifier to an openly available assigning authority, such as National Association of Insurance Commissioners (NAIC) (2.16.840.1.113883.6.300), and the extension identifiers the payer within that authority. #xD; code 0..1 CE #xD; @nullFlavor 0..0 #xD; @code 1..1 cs Binding: Financially Responsible Party Type Value Set (preferred) #xD; addr 0..1 USRealmAddress #xD; telecom 0..* TEL #xD; representedOrganization C 0..1 Organization Constraints: should-name #xD; name 0..1 ON #xD; performer:guarantor C 0..* Performer2 This performer represents the Guarantor. Constraints: should-time #xD; templateId 1..1 II #xD; @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.88 #xD; @extension 0..0 #xD; @typeCode 1..1 cs #xD; time 0..1 IVL_TS #xD; assignedEntity <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( 4537-8967, should-addr, should-telecom )">C 1..1 AssignedEntity Constraints: 4537-8967, should-addr, should-telecom #xD; code 1..1 CE #xD; @code 1..1 cs Required Pattern: GUAR #xD; @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.5.110 #xD; addr 0..1 USRealmAddress #xD; telecom 0..* TEL #xD; Slices for participant 1..* Participant2 Slice: Unordered, Open by value:typeCode #xD; participant:coverage-target C 1..1 Participant2 participant Constraints: should-time #xD; templateId 1..1 II #xD; @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.89 #xD; @extension 0..0 #xD; @typeCode 1..1 cs Fixed Value: COV #xD; time <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( should-low, should-high )">C 0..1 IVL_TS This records the policy coverage period or self-pay period. Constraints: should-low, should-high #xD; low 0..1 IVXB_TS #xD; high 0..1 IVXB_TS SHOULD contain high #xD; participantRole <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( should-addr, should-playingEntity )">C 1..1 ParticipantRole Constraints: should-addr, should-playingEntity #xD; id 1..* II 헨?헦?헖?헗?헜?: Member Identifier: 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:4537-8984). #xD; code <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( should-code-attr )">C 1..1 CE 헨?헦?헖?헗?헜?: Relationship to Subscriber: Records the relationship of a patient to the primary insured person. Constraints: should-code-attr #xD; @code 0..1 cs Binding: Coverage Role Type Value Set (preferred) #xD; addr 0..1 USRealmAddress #xD; playingEntity 0..1 PlayingEntity This playingEntity records the covered party name and birthTime as represented by the health plan. This could match the information in recordTarget, or be different due to marriage or other reasons. #xD; name 1..1 PN #xD; sdtcBirthTime 1..1 TS sdtc:birthTime #xD; participant:subscriber 0..1 Participant2 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. #xD; templateId 1..1 II #xD; @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.90 #xD; @extension 0..0 #xD; @typeCode 1..1 cs Fixed Value: HLD #xD; time 0..1 IVL_TS #xD; participantRole C 1..1 ParticipantRole Constraints: should-addr #xD; id 1..* II 헨?헦?헖?헗?헜?: Subscriber Id: This id is a unique identifier for the subscriber of the coverage (CONF:4537-10120). #xD; addr 0..1 USRealmAddress #xD; Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by value:act.moodCode #xD; entryRelationship:authorization 0..* EntryRelationship entryRelationship #xD; @typeCode 1..1 cs Fixed Value: REFR #xD; act 1..1 AuthorizationActivity #xD; @moodCode 1..1 cs EVN #xD; entryRelationship:plan 0..* EntryRelationship Represents the Coverage Plan #xD; @typeCode 1..1 cs Fixed Value: REFR #xD; act 1..1 Act #xD; @classCode 1..1 cs Fixed Value: ACT #xD; @moodCode 1..1 cs Fixed Value: DEF #xD; id 1..* II Plan identifier #xD; text 1..1 ED Name of the plan #xD; Documentation for this format
HL7 International - Structured Documents
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. Note that the absence of a Policy Activity Act is not confirmation the patient does not have coverage. A Patient's coverage may not have been documented yet or not known to the healthcare provider. * Absence of a Policy Activity Act may mean that the patient has no coverage or the healthcare provider may not know it. * A self pay payer type MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs. #### Templates Used Although open templates may contain any valid CDA content, the following templates are specifically called out by this template: **Optional EntryRelationships**: [AuthorizationActivity](StructureDefinition-AuthorizationActivity.html)
Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type.
When the Subscriber is the patient (COV participant code = 'SELF'), 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:4537-17139).
participant.where(typeCode='COV').participantRole.code.where(code = 'SELF').exists() implies participant.where(typeCode='HLD').empty()
If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.
When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question
When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.
An II instance must have either a root or an nullFlavor.
A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.
Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).
Identifies the type as an HL7 Registered model
A character string as a unique identifier within the scope of the identifier root.
When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question
A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.
SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:4537-8898).
SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:4537-8899).
𝗨𝗦𝗖𝗗𝗜: Group Identifier: This is the identifier (sent in the @extension attribute) used to uniquely refer to a specific health insurance plan.
If the root OID of Payer that assigned the group identifier is unknown, a local OID can be assigned or a nullFlavor of UNK
𝗨𝗦𝗖𝗗𝗜: Coverage Type: Records the category of health care payers, insurance products, or benefits.
SHOULD reference the portion of section narrative text corresponding to this entry
Indicates whether the raw byte data is compressed, and what compression algorithm was used.
The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.
Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.
For character based information the language property specifies the human language of the text.
Identifies the type of the encapsulated data and identifies a method to interpret or render the data.
Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
Data that is primarily intended for human interpretation or for further machine processing is outside the scope of HL7. This includes unformatted or formatted written language, multimedia data, or structured information as defined by a different standard (e.g., XML-signatures.)
This element is represented in XML as textual content. The actual name "xmlText" will not appear in a CDA instance.
A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.
If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
value.exists() implies value.startsWith('#')
An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.
SHALL contain exactly one [1..1] statusCode (CONF:4537-8902).
The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.
This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: HL7ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:4537-19109).
Specifies the code system that defines the code.
If applicable, a version descriptor defined specifically for the given code system.
A name or title for the code, under which the sending system shows the code value to its users.
The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.
The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.
The text or phrase used as the basis for the coding.
Specifies additional codes that increase the specificity of the the primary code.
A set of other concept descriptors that translate this concept descriptor into other code systems.
SHOULD contain zero or more [0..*] performer (CONF:4537-8961) such that it
SHALL contain exactly one [1..1] performer (CONF:4537-8906) such that it
SHALL contain exactly one [1..1] templateId (CONF:4537-16808), SHALL not contain [0..0] extension..
This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.87" Payer Performer (CONF:4537-16809).
SHALL contain exactly one [1..1] assignedEntity (CONF:4537-8908).
𝗨𝗦𝗖𝗗𝗜: Payer Identifier: This is the Payer id. The root is a unique identifier to an openly available assigning authority, such as National Association of Insurance Commissioners (NAIC) (2.16.840.1.113883.6.300), and the extension identifiers the payer within that authority.
This assignedEntity SHALL contain at least one [1..*] id (CONF:4537-8909).
This assignedEntity SHOULD contain zero or one [0..1] code (CONF:4537-8914).
This assignedEntity MAY contain zero or one [0..1] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-8910).
This assignedEntity MAY contain zero or more [0..*] telecom (CONF:4537-8911).
This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:4537-8912).
The representedOrganization, if present, SHOULD contain zero or one [0..1] name (CONF:4537-8913).
This performer represents the Guarantor.
SHALL contain exactly one [1..1] templateId (CONF:4537-16810), SHALL not contain [0..0] extension.
This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.88" Guarantor Performer (CONF:4537-16811).
SHOULD contain zero or one [0..1] time (CONF:4537-8963).
SHALL contain exactly one [1..1] assignedEntity (CONF:4537-8962).
**SHOULD** include assignedEntity/assignedPerson/name AND/OR assignedEntity/representedOrganization/name (CONF:4537-8967).
assignedPerson.name.exists() or representedOrganization.name.exists()
This assignedEntity SHALL contain exactly one [1..1] code (CONF:4537-8968).
This code SHALL contain exactly one [1..1] @code="GUAR" Guarantor (CONF:4537-16096).
This assignedEntity SHOULD contain zero or one [0..1] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-8964).
This assignedEntity SHOULD contain zero or more [0..*] telecom (CONF:4537-8965).
SHOULD contain zero or one [0..1] participant (CONF:4537-8934) such that it
SHALL contain exactly one [1..1] participant (CONF:4537-8916) such that it
SHALL contain exactly one [1..1] templateId (CONF:4537-16812), SHALL not contain [0..0] extension.
This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.89" Covered Party Participant (CONF:4537-16814).
SHALL contain exactly one [1..1] @typeCode="COV" Coverage target (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:4537-8917).
This records the policy coverage period or self-pay period.
SHOULD contain zero or one [0..1] time (CONF:4537-8918).
A quantity specifying a point on the axis of natural time. A point in time is most often represented as a calendar expression.
A code specifying whether the set component is included (union) or excluded (set-difference) from the set, or other set operations with the current set component and the set as constructed from the representation stream up to the current point.
The time, if present, SHOULD contain zero or one [0..1] low (CONF:4537-8919).
The arithmetic mean of the interval (low plus high divided by 2). The purpose of distinguishing the center as a semantic property is for conversions of intervals from and to point values.
The difference between high and low boundary. The purpose of distinguishing a width property is to handle all cases of incomplete information symmetrically. In any interval representation only two of the three properties high, low, and width need to be stated and the third can be derived.
The time, if present, SHOULD contain zero or one [0..1] high (CONF:4537-8920).
SHALL contain exactly one [1..1] participantRole (CONF:4537-8921).
𝗨𝗦𝗖𝗗𝗜: Member Identifier: 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:4537-8984).
This participantRole SHALL contain at least one [1..*] id (CONF:4537-8922).
𝗨𝗦𝗖𝗗𝗜: Relationship to Subscriber: Records the relationship of a patient to the primary insured person.
This participantRole SHALL contain exactly one [1..1] code (CONF:4537-8923).
This code SHOULD contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Coverage Role Type Value Set urn:oid:2.16.840.1.113883.1.11.18877 DYNAMIC (CONF:4537-16078).
This participantRole SHOULD contain zero or one [0..1] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-8956).
This playingEntity records the covered party name and birthTime as represented by the health plan. This could match the information in recordTarget, or be different due to marriage or other reasons.
This participantRole SHOULD contain zero or one [0..1] playingEntity (CONF:4537-8932).
The playingEntity, if present, SHALL contain exactly one [1..1] name (CONF:4537-8930).
The purpose of this extension is to allow the recording of the subscriber or member of a health plan in cases where the health plan eligibility system has different information on file than the provider does for the patient.
The playingEntity, if present, SHALL contain exactly one [1..1] sdtc:birthTime (CONF:4537-31344).
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.
SHALL contain exactly one [1..1] templateId (CONF:4537-16813), SHALL not contain [0..0] extension.
This templateId SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.90" Policy Holder Participant (CONF:4537-16815).
SHALL contain exactly one [1..1] @typeCode="HLD" Holder (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:4537-8935).
MAY contain zero or one [0..1] time (CONF:4537-8938).
SHALL contain exactly one [1..1] participantRole (CONF:4537-8936).
𝗨𝗦𝗖𝗗𝗜: Subscriber Id: This id is a unique identifier for the subscriber of the coverage (CONF:4537-10120).
This participantRole SHALL contain at least one [1..*] id (CONF:4537-8937).
This participantRole SHOULD contain zero or one [0..1] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:4537-8925).
MAY contain one [0..*] entryRelationship (CONF:4537-8939) such that it
SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:4537-8940).
The entryRelationship.inversionInd can be set to "true" to indicate that the relationship should be interpreted as if the roles of the source and target entries were reversed.
The entryRelationship.contextConductionInd differs from the otherwise common use of this attribute in that in all other cases where this attribute is used, the value is fixed at "true", whereas here the value is defaulted to "true", and can be changed to "false" when referencing an entry in the same document. Setting the context conduction to false when referencing an entry in the same document keeps clear the fact that the referenced object retains its original context.
SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-8944).
SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-8945).
SHALL contain exactly one [1..1] id (CONF:81-8947).
The target of an authorization activity MAY contain one or more performer, to indicate the providers that have been authorized to provide treatment (CONF:81-8952).
SHALL contain at least one [1..*] entryRelationship (CONF:81-8948) such that it
The target of an authorization activity with act/entryRelationship/@typeCode="SUBJ" SHALL be a clinical statement with moodCode="PRMS" Promise (CONF:81-8951).
(act | encounter | observation | observationMedia | organizer | procedure | regionOfInterest | substanceAdministration | supply).where(moodCode='PRMS').exists()
SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:81-8949).
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:4537-8943).