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 - TTL Representation

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

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:CodeSystem ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "crd-coverage-detail"] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div [ fhir:v "<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\">  allowed-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\">  allowed-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\">  in-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\">  out-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\">  concurrent-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\">  appropriate-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\">  policy-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>"^^rdf:XMLLiteral ]
  ] ; # 
  fhir:extension ( [
fhir:url [
fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-wg>     ] ;
fhir:value [
a fhir:Code ;
fhir:v "fm"     ]
  ] [
fhir:url [
fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm>     ] ;
fhir:value [
a fhir:Integer ;
fhir:v 1     ]
  ] ) ; # 
  fhir:url [
fhir:v "http://terminology.hl7.org/CodeSystem/crd-coverage-detail"^^xsd:anyURI ;
fhir:l <http://terminology.hl7.org/CodeSystem/crd-coverage-detail>
  ] ; # 
  fhir:identifier ( [
fhir:system [
fhir:v "urn:ietf:rfc:3986"^^xsd:anyURI ;
fhir:l <urn:ietf:rfc:3986>     ] ;
fhir:value [ fhir:v "urn:oid:2.16.840.1.113883.5.177" ]
  ] ) ; # 
  fhir:version [ fhir:v "1.0.0"] ; # 
  fhir:name [ fhir:v "CRDCoverageDetail"] ; # 
  fhir:title [ fhir:v "CRD Coverage Detail Codes"] ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:experimental [ fhir:v false] ; # 
  fhir:date [ fhir:v "2025-10-16T00:00:00+00:00"^^xsd:dateTime] ; # 
  fhir:publisher [ fhir:v "Health Level Seven International"] ; # 
  fhir:contact ( [
    ( fhir:telecom [
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://hl7.org" ]     ] [
fhir:system [ fhir:v "email" ] ;
fhir:value [ fhir:v "hq@HL7.org" ]     ] )
  ] ) ; # 
  fhir:description [ fhir:v "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."] ; # 
  fhir:copyright [ fhir:v "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"] ; # 
  fhir:caseSensitive [ fhir:v true] ; # 
  fhir:hierarchyMeaning [ fhir:v "is-a"] ; # 
  fhir:content [ fhir:v "complete"] ; # 
  fhir:property ( [
fhir:code [ fhir:v "abstract" ] ;
fhir:uri [
fhir:v "http://hl7.org/fhir/concept-properties#notSelectable"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/concept-properties#notSelectable>     ] ;
fhir:type [ fhir:v "boolean" ]
  ] ) ; # 
  fhir:concept ( [
fhir:code [ fhir:v "_limitation" ] ;
fhir:display [ fhir:v "Limitation details" ] ;
fhir:definition [ fhir:v "Identifies detail codes that define limitations of coverage.  (Category should be 'cat-limitation')" ] ;
    ( fhir:property [
fhir:code [ fhir:v "abstract" ] ;
fhir:value [
a fhir:Boolean ;
fhir:v true       ]     ] ) ;
    ( fhir:concept [
fhir:code [ fhir:v "allowed-quantity" ] ;
fhir:display [ fhir:v "Maximum quantity" ] ;
fhir:definition [ fhir:v "Indicates limitations on the number of services/products allowed (possibly per time period).  Value should be a Quantity" ]     ] [
fhir:code [ fhir:v "allowed-period" ] ;
fhir:display [ fhir:v "Maximum allowed period" ] ;
fhir:definition [ fhir:v "Indicates the maximum period of time that can be covered in a single order.  Value should be a Period" ]     ] )
  ] [
fhir:code [ fhir:v "_decisional" ] ;
fhir:display [ fhir:v "Decisional details" ] ;
fhir:definition [ fhir:v "Identifies detail codes that may impact patient and clinician decision making  (Category should be 'cat-decisional')" ] ;
    ( fhir:property [
fhir:code [ fhir:v "abstract" ] ;
fhir:value [
a fhir:Boolean ;
fhir:v true       ]     ] ) ;
    ( fhir:concept [
fhir:code [ fhir:v "in-network-copay" ] ;
fhir:display [ fhir:v "Copay for in-network" ] ;
fhir:definition [ fhir:v "Indicates a percentage co-pay to expect if delivered in-network.  Value should be a Quantity." ]     ] [
fhir:code [ fhir:v "out-network-copay" ] ;
fhir:display [ fhir:v "Copay for out-of-network" ] ;
fhir:definition [ fhir:v "Indicates a percentage co-pay to expect if delivered out-of-network.  Value should be a Quantity." ]     ] [
fhir:code [ fhir:v "concurrent-review" ] ;
fhir:display [ fhir:v "Concurrent review" ] ;
fhir:definition [ fhir:v "Additional payer-defined documentation will be required prior to claim payment.  Value should be a boolean." ]     ] [
fhir:code [ fhir:v "appropriate-use-needed" ] ;
fhir:display [ fhir:v "Appropriate use" ] ;
fhir:definition [ fhir:v "Payer-defined appropriate use process must be invoked to determine coverage.  Value should be a boolean." ]     ] )
  ] [
fhir:code [ fhir:v "_other" ] ;
fhir:display [ fhir:v "Other details" ] ;
fhir:definition [ fhir:v "Identifies detail codes that are generally not relevant to clinicians/patients  (Category should be 'cat-other')" ] ;
    ( fhir:property [
fhir:code [ fhir:v "abstract" ] ;
fhir:value [
a fhir:Boolean ;
fhir:v true       ]     ] ) ;
    ( fhir:concept [
fhir:code [ fhir:v "policy-link" ] ;
fhir:display [ fhir:v "Policy Link" ] ;
fhir:definition [ fhir:v "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." ]     ] )
  ] [
fhir:code [ fhir:v "instructions" ] ;
fhir:display [ fhir:v "Instructions" ] ;
fhir:definition [ fhir:v "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.)" ]
  ] ) . #