Consumer-Directed Payer Data Exchange
- Release 0.1.0

Consumer-Directed Payer Data Exchange, published by CARIN Alliance. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Coverage mapping

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Slice L0 L1 L2 L3 L4 Flag Cardinality DataType /
Value Set
Description MapID CPCDS Data Element Name Cardinality /
DataType
Value Set Comments Working Note
Coverage TU DomainResource Insurance or medical plan or a payment agreement
Coverage Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
Coverage extension medicalCOB 1..* CodeableConcept Indicates whether the Plans responsibility for this member's coverage is primary or secondary. 76 [1..1] CHAR(1) P - for Primary | S for Secondary | M - Secondary to Medicare | N - No Medical / Pharmacy Coverage | A - Primary Under Non-Commercial Product (Medicare Advantage or Other)
Coverage identifier Σ 0..* Identifier Business Identifier for the coverage
Coverage status ?!Σ 1..1 code active | cancelled | draft | entered-in-error New default: active
Coverage status Financial Resource Status Codes (Required) New
Coverage type Σ 0..1 CodeableConcept Coverage category such as medical or accident 3 [1..*]
Coverage type Coverage Type and Self-Pay Codes (Preferred) 3
Coverage policyHolder Σ 0..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
Coverage subscriber Σ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
Coverage subscriberId Σ 0..1 string ID assigned to the subscriber
Coverage beneficiary--> Σ 1..1 Reference(Patient) Plan beneficiary Ref (1) Member id [1..1]CHAR (22)
Coverage beneficiary--> Σ 1..1 Reference(Patient) Plan beneficiary Ref (70) Date of birth [1..1] (TS8)
Coverage beneficiary--> Σ 1..1 Reference(Patient) Plan beneficiary Ref (124) Date of death [1..1] (TS8)
Coverage beneficiary--> Σ 1..1 Reference(Patient) Plan beneficiary Ref (71) Gender code [1..1] (CD-CHAR(1))
Coverage dependent Σ 0..1 string Dependent number
Coverage relationship 0..1 CodeableConcept Beneficiary relationship to the subscriber 72 Relationship to subscriber [1..1] (CD-CHAR(2)) coding.system = url of code system
coding.code = the code value
Coverage relationship SubscriberPolicyholder Relationship Codes (Extensible) 72 Relationship to subscriber [1..1] (CD-CHAR(2))
Coverage period Σ 0..1 Period Coverage start and end dates 74, 75
Coverage payor--> Σ 1..1 Reference(Organization) Issuer of the policy Ref (2)
Ref (140)
Claim Payer Identifier, Claim Primary Payer Identifier
Coverage class 0..* BackboneElement Additional coverage classifications
Coverage class type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Coverage class type Coverage Class Codes (Extensible)
Coverage class value Σ 1..1 string Value associated with the type
Coverage class name Σ 0..1 string Human readable description of the type and value
Coverage order Σ 0..1 positiveInt Relative order of the coverage 76 [1..1] NUMERIC(1)
Coverage network Σ 0..1 string Insurer network
Coverage costToBeneficiary 0..* BackboneElement Patient payments for services/products
Coverage costToBeneficiary type Σ 0..1 CodeableConcept Cost category
Coverage costToBeneficiary type Coverage Copay Type Codes (Extensible)
Coverage costToBeneficiary value Σ 1..1 The amount or percentage due from the beneficiary
Coverage costToBeneficiary value valueQuantity SimpleQuantity
Coverage costToBeneficiary value valueMoney Money
Coverage costToBeneficiary exception 0..* BackboneElement Exceptions for patient payments
Coverage costToBeneficiary exception type Σ 1..1 CodeableConcept Exception category
Coverage costToBeneficiary exception type Example Coverage Financial Exception Codes (Example)
Coverage costToBeneficiary exception period Σ 0..1 Period The effective period of the exception
Coverage subrogation 0..1 boolean Reimbursement to insurer
Coverage contract 0..* Reference(Contract) Contract details
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