Da Vinci - Coverage Requirements Discovery
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Da Vinci - Coverage Requirements Discovery, published by HL7 International - Financial Management Work Group. This is not an authorized publication; it is the continuous build for version 1.1.0-ci-build). This version is based on the current content of https://github.com/HL7/davinci-crd/ and changes regularly. See the Directory of published versions

CRD IG Home Page

Official URL: http://hl7.org/fhir/us/davinci-crd/ImplementationGuide/hl7.fhir.us.davinci-crd Version: 1.1.0-ci-build
Draft as of 2023-05-27 Computable Name: CoverageRequirementsDiscovery

This ballot release of the specification reflects several changes that reflect implementer feedback about the CRD specification arising from detailed review, connectathons and implementation experience. Significant changes to the specification are highlighted in green and balloters are invited to focus particular attention on these sections. "Notes to balloters" and "STU notes" call out additional key considerations where feedback is desired. However, the whole specification is open to review and the project welcomes all constructive feedback.

A summary of the major changes in this release can be found here.

This specification is a Standard for Trial Use. It is expected to continue to evolve and improve through connectathon testing and feedback from early adopters.

Feedback is welcome and may be submitted through the FHIR change tracker indicating "US Da Vinci CRD" as the specification.

This implementation guide is dependent on other specifications. Please submit any comments you have on these base specifications as follows:

  • Feedback on CDS Hooks should be posted to the FHIR change tracker with "CDS Hooks" as the specification.
  • Feedback on the FHIR core specification should be submitted to the FHIR change tracker with "FHIR Core" as the specification.
  • Feedback on the US core profiles should be submitted to the FHIR change tracker with "US Core" as the specification.

Individuals interested in participating in the Coverage Requirements Discovery or other HL7 Da Vinci projects can find information about Da Vinci [here](http://www.hl7.org/about/davinci).


The process of managing billing for patient insurance is a significant source of complexity and cost in the United States. Healthcare providers work with a range of different health insurers and payers who cover the services the providers supply to patients. Different payers and plans provide different levels of coverage for healthcare services with different processes for determining whether services are necessary or are appropriate. These processes have different requirements for documentation, prior authorization, or other approvals. Claims submitted for payment that do not meet payer coverage or documentation requirements will typically be initially denied and may result in delays due to resubmission, appeals, and/or financial impact to the patient.

This Coverage Requirements Discovery (CRD) implementation guide defines a workflow to allow payers to provide information about coverage requirements to healthcare providers through their provider systems at the time treatment decisions are being made. This will ensure that clinicians and administrative staff have the capability to make informed decisions and meet the requirements of the patient’s insurance coverage.

This implementation guide supports both Protected Health Information (PHI)-specific and non-PHI mechanisms for CRD to meet the needs and privileges of different payer organizations. These mechanisms will allow payers to share a wide variety of information with providers in a context-sensitive manner including:

  • updates to coverage information
  • alternative (e.g. first-line, lower-cost, etc.) services or products
  • documentation requirements and rules related to coverage
  • forms and templates to complete
  • indications of whether a therapy is covered or prior authorization is required, including propagating this information into the relevant order/appointment

This implementation guide is designed to allow for initial support of basic capabilities and to subsequently build new features over time.


This implementation guide sets expectations for two types of systems:

CRD Clients are typically systems that healthcare providers use at the point of care, including electronic medical records systems, pharmacy systems, and other provider and administrative systems used for ordering, documenting, and execution of patient-related services. Users of these systems have a need for coverage requirements information to support care planning.

Examples of potential CRD clients include EHRs, EMRs, practice management systems, scheduling systems, patient registration systems, etc.

The CRD client may actually involve multiple systems. For example, the systems that handle order entry may be different from what is used for appointment booking and different again from the system that exposes information over the FHIR interface. It is possible that a provider environment might use an intermediary to coordinate CRD client calls from multiple systems. Such an architecture is sufficient provided that:

  • Calls are triggered from within the system the user is interacting with at the time the ‘hook event’ (entering an order, booking an appointment, etc.) occurs.
  • Cards returned are displayed to the user, or in the event of system actions, user-notifications associated with the system actions occur in the application the user was interacting with.
  • The ‘access token’ and FHIR endpoint exposed to the CRD service has access to all relevant data, independent of which physical data store it resides in.
  • The intermediary could take on the responsibility for the FHIR interface, determining appropriate payer to route calls to, etc.

When CRD clients are made up of multiple systems, there will be orchestration requirements to allow these multiple systems to interact in a way that allows them to appear as a single monolithic system from the perspective of the CRD server. This IG does not (yet) provide any guidance or standardization about how system components should interoperate to achieve this monolithic behavior. If there is industry interest, future releases of this IG may work to standardize some of these "intra-client" interactions.

CRD Servers (or servers) are systems that act on behalf of payer organizations to share information with healthcare providers about rules and requirements related to healthcare products and services covered by a patient’s payer. A CRD Server might provide coverage information related to one or more insurance plans. CRD Servers are a type of CDS Service as defined in the CDS Hooks Specification.

Payers may have multiple back-end functions that handle different types of decision support and/or different types of services. However, for the purpose of CRD conformance, payers SHALL have a single endpoint (managed by themselves or a delegate) that can handle responding to all CRD service calls. CRD servers are free to route the information from those calls to back-end services as needed. This routing may evolve over time and should have no impact on CRD client calls.

Content and Organization

This implementation guide is organized into the following sections:

  • Use Cases and Overview describes the intent of the implementation guide, gives examples of its use, and provides a high-level overview of expected process flow
  • Technical Background identifies related specifications this implementation guide builds upon that developers should read and understand prior to implementing this specification
  • Foundational Guidance covers the detailed requirements and conformance expectations that apply to all implementations
  • Deviations and Enhancements covers detailed implementation requirements and conformance expectations that are independent of particular hooks or cards
  • Supported Hooks identifies the expectations for support for specific CDS hooks
  • Card Profiles defines patterns for CDS Hook cards that can be returned as part of this specification
  • Implementation Guidance that provides recommendations for implementation that fall outside the technical scope of the specification
  • Artifacts introduces and provides links to the profiles, search parameters and other FHIR artifacts used in this implementation guide
  • Downloads allows download of this and other specifications as well as other useful files
  • Credits identifies the individuals and organizations involved in developing this implementation guide


This guide is based on the FHIR R4 specification that is mandated for use in the U.S. as well as the CDS Hooks 2.0 and CDS Hooks CI Build releases of the CDS hooks specification. It also leverages the SMART on FHIR specification for CRD clients that opt to use that approach for “what-if” scenarios.

In addition, this guide also relies on a number of parent implementation guides:

.. Da Vinci - Coverage Requirements Discoveryhl7.fhir.us.davinci-crd#1.1.0-ci-buildR4
... HL7 Terminology (THO)hl7.terminology.r4#5.0.0R4Automatically added as a dependency - all IGs depend on HL7 Terminology
... FHIR Extensions Packhl7.fhir.uv.extensions.r4#1.0.0R4Automatically added as a dependency - all IGs depend on the HL7 Extension Pack
... US Corehl7.fhir.us.core#3.1.1R4
... Da Vinci Health Record Exchange (HRex)hl7.fhir.us.davinci-hrex#1.0.0R4
... Structured Data Capturehl7.fhir.uv.sdc#3.0.0R4

This implementation guide defines additional constraints and usage expectations above and beyond the information found in these base specifications.

###Intellectual Property Considerations This implementation guide and the underlying FHIR specification are licensed as public domain under the FHIR license. The license page also describes rules for the use of the FHIR name and logo.

This publication includes IP covered under the following statements.

This publication includes IP covered under the following statements.