HL7 Terminology (THO)
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HL7 Terminology (THO), published by HL7 International - Vocabulary Work Group. This guide is not an authorized publication; it is the continuous build for version 7.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/UTG/ and changes regularly. See the Directory of published versions

: CRD Coverage Detail Codes - JSON Representation

Active as of 2025-10-16 Maturity Level: 1

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{
  "resourceType" : "CodeSystem",
  "id" : "crd-coverage-detail",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CodeSystem crd-coverage-detail</b></p><a name=\"crd-coverage-detail\"> </a><a name=\"hccrd-coverage-detail\"> </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://terminology.hl7.org/CodeSystem/crd-coverage-detail</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\">_limitation<a name=\"crd-coverage-detail-_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=\"crd-coverage-detail-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=\"crd-coverage-detail-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=\"crd-coverage-detail-_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=\"crd-coverage-detail-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=\"crd-coverage-detail-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=\"crd-coverage-detail-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=\"crd-coverage-detail-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=\"crd-coverage-detail-_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=\"crd-coverage-detail-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=\"crd-coverage-detail-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></table></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode" : "fm"
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
      "valueInteger" : 1
    }
  ],
  "url" : "http://terminology.hl7.org/CodeSystem/crd-coverage-detail",
  "identifier" : [
    {
      "system" : "urn:ietf:rfc:3986",
      "value" : "urn:oid:2.16.840.1.113883.5.177"
    }
  ],
  "version" : "1.0.0",
  "name" : "CRDCoverageDetail",
  "title" : "CRD Coverage Detail Codes",
  "status" : "active",
  "experimental" : false,
  "date" : "2025-10-16T00:00:00+00:00",
  "publisher" : "Health Level Seven International",
  "contact" : [
    {
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://hl7.org"
        },
        {
          "system" : "email",
          "value" : "hq@HL7.org"
        }
      ]
    }
  ],
  "description" : "Codes that describe additional details related to a coverage information assertion.  These live in THO rather than the CRD specification to support adding additional concepts without putting out a new CRD release.",
  "copyright" : "This material derives from the HL7 Terminology (THO). THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license",
  "caseSensitive" : true,
  "hierarchyMeaning" : "is-a",
  "content" : "complete",
  "property" : [
    {
      "code" : "abstract",
      "uri" : "http://hl7.org/fhir/concept-properties#notSelectable",
      "type" : "boolean"
    }
  ],
  "concept" : [
    {
      "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
        }
      ],
      "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.)"
    }
  ]
}