Da Vinci - Coverage Requirements Discovery
2.1.0 - STU 2.1
Da Vinci - Coverage Requirements Discovery
2.1.0 - STU 2.1
Da Vinci - Coverage Requirements Discovery, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) 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
| Page standards status: Informative |
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:MedicationRequest ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "annotated-example"] ; #
fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: MedicationRequest annotated-example</b></p><a name=\"annotated-example\"> </a><a name=\"hcannotated-example\"> </a><a name=\"annotated-example-en-US\"> </a><blockquote><p><b>Coverage Information</b></p><blockquote><p><b>url</b></p><a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/coverage\">coverage</a></blockquote><p><b>value</b>: <a href=\"Coverage-example.html\">Coverage: identifier = Member Number; status = active; type = extended healthcare; dependent = 0; relationship = Self; period = 2011-05-23 --> 2012-05-23</a></p><blockquote><p><b>url</b></p><a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/covered\">covered</a></blockquote><p><b>value</b>: conditional</p><blockquote><p><b>url</b></p><a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/pa-needed\">pa-needed</a></blockquote><p><b>value</b>: satisfied</p><blockquote><p><b>url</b></p><a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/doc-needed\">doc-needed</a></blockquote><p><b>value</b>: admin</p><blockquote><p><b>url</b></p><a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/doc-purpose\">doc-purpose</a></blockquote><p><b>value</b>: withclaim</p><blockquote><p><b>url</b></p><a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/info-needed\">info-needed</a></blockquote><p><b>value</b>: performer</p><blockquote><p><b>url</b></p><a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/billingCode\">billingCode</a></blockquote><p><b>value</b>: <a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-CPT.html#CPT-77067\">Current Procedural Terminology (CPT®) 77067</a>: Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed</p><blockquote><p><b>url</b></p><a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/reason\">reason</a></blockquote><p><b>value</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp gold-card}\">In-network required unless exigent circumstances</span></p><p><b>code</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp auth-out-network-only}\">Authorization out-of-network only</span></p><p><b>value</b>: true</p><p><b>qualification</b>: Out-of-network prior auth does not apply if delivery occurs at a service site designated as 'remote'</p><blockquote><p><b>url</b></p><a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/detail\">detail</a></blockquote><blockquote><p><b>url</b></p><a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/questionnaire\">questionnaire</a></blockquote><p><b>value</b>: <a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://example.org/some-payer/Questionnaire/123|1.3.0\">http://example.org/some-payer/Questionnaire/123|1.3.0</a></p><blockquote><p><b>url</b></p><a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/date\">date</a></blockquote><p><b>value</b>: 2019-02-15</p><blockquote><p><b>url</b></p><a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/coverage-assertion-id\">coverage-assertion-id</a></blockquote><p><b>value</b>: 12345ABC</p><blockquote><p><b>url</b></p><a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/satisfied-pa-id\">satisfied-pa-id</a></blockquote><p><b>value</b>: XXYYZ</p><blockquote><p><b>url</b></p><a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/contact\">contact</a></blockquote><p><b>value</b>: <a href=\"http://some-payer.org/xyz-sub-org/get-help-here.html\">http://some-payer.org/xyz-sub-org/get-help-here.html</a></p><blockquote><p><b>url</b></p><a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/expiry-date\">expiry-date</a></blockquote><p><b>value</b>: 2019-08-01</p></blockquote><p><b>status</b>: Draft</p><p><b>intent</b>: Original Order</p><p><b>medication</b>: <span title=\"Codes:{http://www.nlm.nih.gov/research/umls/rxnorm 616447}\">mycophenolate mofetil 250 MG Oral Capsule [Cellcept]</span></p><p><b>subject</b>: <a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://example.org/Patient/123\">Jane Smith</a></p><p><b>encounter</b>: <a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://example.org/Encounter/ABC\">??</a></p><p><b>authoredOn</b>: 2019-02-15</p><p><b>requester</b>: <a href=\"https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://example.org/PractitionerRole/987\">Dr. Jones</a></p><p><b>note</b>: Unsolicited prior authorization for Jane Smith to receive 6 tablets Cellcept 250 MG Oral Capsule BID granted. Please note prior authorization # 12345 on claim submission. (By XYZ Insurance @2019-02-15 15:07:18-0500)</p><blockquote><p><b>dosageInstruction</b></p><p><b>text</b>: 6 tablets every 12 hours.</p><p><b>timing</b>: Once per 12 hours</p><h3>DoseAndRates</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Dose[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>6 tablet</td></tr></table></blockquote></div>"
] ; #
fhir:extension ( [
( fhir:extension [
fhir:url [ fhir:v "coverage"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "Coverage/example" ] ] ] [
fhir:url [ fhir:v "covered"^^xsd:anyURI ] ;
fhir:value [ fhir:v "conditional" ] ] [
fhir:url [ fhir:v "pa-needed"^^xsd:anyURI ] ;
fhir:value [ fhir:v "satisfied" ] ] [
fhir:url [ fhir:v "doc-needed"^^xsd:anyURI ] ;
fhir:value [ fhir:v "admin" ] ] [
fhir:url [ fhir:v "doc-purpose"^^xsd:anyURI ] ;
fhir:value [ fhir:v "withclaim" ] ] [
fhir:url [ fhir:v "info-needed"^^xsd:anyURI ] ;
fhir:value [ fhir:v "performer" ] ] [
fhir:url [ fhir:v "billingCode"^^xsd:anyURI ] ;
fhir:value [
a fhir:Coding ;
fhir:system [ fhir:v "http://www.ama-assn.org/go/cpt"^^xsd:anyURI ] ;
fhir:code [ fhir:v "77067" ] ] ] [
fhir:url [ fhir:v "reason"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp"^^xsd:anyURI ] ;
fhir:code [ fhir:v "gold-card" ] ] ) ;
fhir:text [ fhir:v "In-network required unless exigent circumstances" ] ] ] [
( fhir:extension [
fhir:url [ fhir:v "code"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp"^^xsd:anyURI ] ;
fhir:code [ fhir:v "auth-out-network-only" ] ] ) ] ] [
fhir:url [ fhir:v "value"^^xsd:anyURI ] ;
fhir:value [ fhir:v "true"^^xsd:boolean ] ] [
fhir:url [ fhir:v "qualification"^^xsd:anyURI ] ;
fhir:value [ fhir:v "Out-of-network prior auth does not apply if delivery occurs at a service site designated as 'remote'" ] ] ) ;
fhir:url [ fhir:v "detail"^^xsd:anyURI ] ] [
fhir:url [ fhir:v "questionnaire"^^xsd:anyURI ] ;
fhir:value [
fhir:v "http://example.org/some-payer/Questionnaire/123|1.3.0"^^xsd:anyURI ;
fhir:link <http://example.org/some-payer/Questionnaire/123|1.3.0> ] ] [
fhir:url [ fhir:v "date"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2019-02-15"^^xsd:date ] ] [
fhir:url [ fhir:v "coverage-assertion-id"^^xsd:anyURI ] ;
fhir:value [ fhir:v "12345ABC" ] ] [
fhir:url [ fhir:v "satisfied-pa-id"^^xsd:anyURI ] ;
fhir:value [ fhir:v "XXYYZ" ] ] [
fhir:url [ fhir:v "contact"^^xsd:anyURI ] ;
fhir:value [
a fhir:ContactPoint ;
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://some-payer.org/xyz-sub-org/get-help-here.html" ] ] ] [
fhir:url [ fhir:v "expiry-date"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2019-08-01"^^xsd:date ] ] ) ;
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information"^^xsd:anyURI ]
] ) ; #
fhir:status [ fhir:v "draft"] ; #
fhir:intent [ fhir:v "original-order"] ; #
fhir:medication [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "http://www.nlm.nih.gov/research/umls/rxnorm"^^xsd:anyURI ] ;
fhir:code [ fhir:v "616447" ] ;
fhir:display [ fhir:v "mycophenolate mofetil 250 MG Oral Capsule [Cellcept]" ] ] )
] ; #
fhir:subject [
fhir:link <http://example.org/Patient/123> ;
fhir:reference [ fhir:v "http://example.org/Patient/123" ] ;
fhir:display [ fhir:v "Jane Smith" ]
] ; #
fhir:encounter [
fhir:link <http://example.org/Encounter/ABC> ;
fhir:reference [ fhir:v "http://example.org/Encounter/ABC" ]
] ; #
fhir:authoredOn [ fhir:v "2019-02-15"^^xsd:date] ; #
fhir:requester [
fhir:link <http://example.org/PractitionerRole/987> ;
fhir:reference [ fhir:v "http://example.org/PractitionerRole/987" ] ;
fhir:display [ fhir:v "Dr. Jones" ]
] ; #
fhir:note ( [
fhir:author [ fhir:v "XYZ Insurance" ] ;
fhir:time [ fhir:v "2019-02-15T15:07:18-05:00"^^xsd:dateTime ] ;
fhir:text [ fhir:v "Unsolicited prior authorization for Jane Smith to receive 6 tablets Cellcept 250 MG Oral Capsule BID granted. Please note prior authorization # 12345 on claim submission." ]
] ) ; #
fhir:dosageInstruction ( [
fhir:text [ fhir:v "6 tablets every 12 hours." ] ;
fhir:timing [
fhir:repeat [
fhir:frequency [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:period [ fhir:v "12"^^xsd:decimal ] ;
fhir:periodUnit [ fhir:v "h" ] ] ] ;
( fhir:doseAndRate [
fhir:dose [
a fhir:Quantity ;
fhir:value [ fhir:v "6"^^xsd:decimal ] ;
fhir:unit [ fhir:v "tablet" ] ] ] )
] ) . #
IG © 2019+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-crd#2.1.0 based on FHIR 4.0.1. Generated 2024-12-11
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