Generated Narrative: StructureDefinition ext-coverage-information Name Flags Card. Type Description & Constraints Extension <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R4/conformance-rules.html#constraints" title="This element has or is affected by constraints ( crd-ci-q1, crd-ci-q2, crd-ci-q3, crd-ci-q4, crd-ci-q5, crd-ci-q6, crd-ci-q7, crd-ci-q8 )">C 0..* Extension CoverageInfo Constraints: crd-ci-q1, crd-ci-q2, crd-ci-q3, crd-ci-q4, crd-ci-q5, crd-ci-q6, crd-ci-q7, crd-ci-q8 #xD; extension 4..* Extension Extension #xD; Slices for extension Content/Rules for all slices #xD; extension:coverage S 1..1 Extension Reference to Coverage #xD; extension 0..0 Extension #xD; url 1..1 uri "coverage" #xD; value[x] 1..1 Reference(CRD Coverage) Value of extension #xD; <a href="StructureDefinition-ext-coverage-information-definitions.html#Extension.extension:covered" title="Slice covered: Indicates whether the ordered/requested service is covered under patient's plan. This includes checking whether the proposed service is a benefit under the patient's plan. It **MAY** also involve checking whether the patient has reached their limits under the current plan period but is not required to.">extension:covered S 1..1 Extension covered | not-covered | conditional #xD; extension 0..0 Extension #xD; url 1..1 uri "covered" #xD; value[x] 1..1 code Value of extension Binding: CRD Coverage Information Covered Value Set (required) #xD; extension:pa-needed S<a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R4/conformance-rules.html#constraints" title="This element has or is affected by constraints ( crd-ci-q2, crd-ci-q5 )">C 0..1 Extension no-auth | auth-needed | satisfied | performpa | conditional #xD; extension 0..0 Extension #xD; url 1..1 uri "pa-needed" #xD; value[x] 1..1 code Value of extension Binding: CRD Coverage Information Prior Authorization Value Set (required) #xD; extension:doc-needed S 0..* Extension clinical | admin | patient | conditional #xD; extension 0..0 Extension #xD; url 1..1 uri "doc-needed" #xD; value[x] 1..1 code Value of extension Binding: CRD Coverage Information Additional Documentation Value Set (required) #xD; extension:doc-purpose SC 0..* Extension withpa | withclaim | withorder | retain-doc | OTH #xD; extension 0..0 Extension #xD; url 1..1 uri "doc-purpose" #xD; value[x] 1..1 code Value of extension Binding: CRD Coverage Information Documentation Reason Value Set (required) #xD; extension:info-needed SC 0..* Extension performer | location | timeframe | contract-window | detail-code | OTH #xD; extension 0..0 Extension #xD; url 1..1 uri "info-needed" #xD; value[x] 1..1 code Value of extension Binding: CRD Information Needed Value Set (required) #xD; extension:billingCode S 0..* Extension Billing code #xD; extension 0..0 Extension #xD; url 1..1 uri "billingCode" #xD; value[x] 1..1 Coding Value of extension Binding: USCLSCodes (example) #xD; extension:reason S<a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R4/conformance-rules.html#constraints" title="This element has or is affected by constraints ( crd-ci-q7, crd-ci-q8, crd-ci-q6 )">C 0..* Extension Reason for assertion #xD; extension 0..0 Extension #xD; url 1..1 uri "reason" #xD; value[x] 1..1 CodeableConcept Value of extension Binding: CRD Coverage Assertion Reasons Value Set (extensible) #xD; extension:detail S 0..* Extension detail for assertion #xD; extension 3..* Extension Extension #xD; Slices for extension Content/Rules for all slices #xD; extension:category 1..1 Extension Type of detail #xD; extension 0..0 Extension #xD; url 1..1 uri "category" #xD; value[x] 0..1 code Value of extension Binding: CRD Coverage Detail Categories Value Set (required) #xD; extension:code 1..1 Extension Name of name-value pair #xD; extension 0..0 Extension #xD; url 1..1 uri "code" #xD; value[x] 0..1 CodeableConcept Value of extension Binding: Official CRD Coverage Detail Codes Value Set (extensible) Additional Bindings Purpose Deprecated CRD Coverage Detail Codes Value Set Extensible #xD; extension:value 1..1 Extension Value of name-value pair #xD; extension 0..0 Extension #xD; url 1..1 uri "value" #xD; value[x] 0..1 Value of extension #xD; valueBoolean boolean #xD; valueString string #xD; valueUrl url #xD; valuePeriod Period #xD; valueQuantity Quantity(SimpleQuantity) #xD; extension:qualification 0..1 Extension Additional info about detail #xD; extension 0..0 Extension #xD; url 1..1 uri "qualification" #xD; value[x] 0..1 string Value of extension #xD; url 1..1 uri "detail" #xD; value[x] 0..0 Value of extension #xD; extension:dependency S 0..* Extension Resources that impact this assertion #xD; extension 0..0 Extension #xD; url 1..1 uri "dependency" #xD; value[x] 0..1 Reference(CRD Appointment with Order | CRD Appointment without Order | CRD Communication Request | CRD Device Request | CRD Medication Request | CRD Nutrition Order | CRD Service Request) Value of extension #xD; extension:questionnaire SC 0..* Extension Questionnaire to complete #xD; extension 0..0 Extension #xD; url 1..1 uri "questionnaire" #xD; value[x] 0..1 canonical(Questionnaire) Value of extension #xD; extension:date S 1..1 Extension Assertion date #xD; extension 0..0 Extension #xD; url 1..1 uri "date" #xD; value[x] 1..1 date Value of extension #xD; extension:coverage-assertion-id S 1..1 Extension Coverage assertion trace number #xD; extension 0..0 Extension #xD; url 1..1 uri "coverage-assertion-id" #xD; value[x] 1..1 string Value of extension #xD; extension:satisfied-pa-id SC 0..1 Extension Satisfied prior auth number #xD; extension 0..0 Extension #xD; url 1..1 uri "satisfied-pa-id" #xD; value[x] 0..1 string Value of extension #xD; extension:contact S 0..* Extension Contact information #xD; extension 0..0 Extension #xD; url 1..1 uri "contact" #xD; value[x] 0..1 ContactDetail Value of extension #xD; extension:expiry-date S 0..1 Extension Expiration date #xD; extension 0..0 Extension #xD; url 1..1 uri "expiry-date" #xD; value[x] 0..1 date Value of extension #xD; url 1..1 uri "http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information" #xD; value[x] 0..0 Value of extension #xD; Documentation for this format
HL7 International / Financial Management
Captures assertions from a payer about the coverage rules for a service - in particular, whether it is covered and/or requires prior authorization.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
Questionnaire is only allowed when doc-needed exists
extension.where(url='questionnaire').exists() implies extension.where(url = 'doc-needed').exists()
If covered is set to 'not-covered', then 'pa-needed' must not exist.
extension.where(url = 'covered' and value = 'not-covered').exists() implies extension.where(url = 'pa-needed').exists().not()
'info-needed' SHALL exist if and only if at least one of 'covered', 'pa-needed', or 'doc-needed' is set to 'conditional'.
extension.where((url = 'covered' or url = 'pa-needed' or url = 'doc-needed') and value = 'conditional').count() >= 1 implies extension.where(url = 'info-needed').exists()
If 'pa-needed' is 'satisfied', 'noauth', or 'not-covered', then 'Doc-purpose' cannot be 'withpa'.
extension.where(url = 'pa-needed' and (value = 'satisfied' or value = 'noauth' or value = 'not-covered')) and extension.where(url = 'doc-purpose').exists() implies extension.where(url = 'doc-purpose').all(value != 'withpa')
'satisfied-pa-id' must exist if and only if 'pa-needed' is set to 'satisfied'.
extension.where(url = 'pa-needed' and value = 'satisfied').exists() = extension.where(url = 'satisfied-pa-id').exists()
If 'info-needed' is OTH, then reason must be specified
extension.where(url = 'info-needed' and value = 'OTH').exists() implies extension.where(url = 'reason').exists()
If reason.coding is present and is not from the extensible value set, then reason.text must be present
extension.where(url = 'reason').empty() or extension.where(url = 'reason').value.text.exists() or extension.where(url = 'reason').value.memberOf('http://hl7.org/fhir/us/davinci-crd/ValueSet/coverageAssertionReasons')
If doc-purpose is present with a value other than 'conditional', then reason must be present
extension.where(url = 'doc-purpose' and value != 'conditional').exists() implies extension.where(url = 'reason').exists()
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
Reference to Coverage that assertion applies to.
This will always be a link to a Coverage resource on the CRD client's system - typically accessed via prefetch or direct query using the CDS-Hooks token. If no coverage instance is available, the coverage-information extension cannot be returned.
Source of the definition for the extension code - a logical name or a URL.
The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
Value of extension - must be one of a constrained set of the data types (see [Extensibility](http://hl7.org/fhir/R4/extensibility.html) for a list).
Indicates whether the ordered/requested service is covered under patient's plan. This includes checking whether the proposed service is a benefit under the patient's plan. It **MAY** also involve checking whether the patient has reached their limits under the current plan period but is not required to.
Details on why coverage does not exist would be conveyed in the 'reason' element.
no-auth | auth-needed | satisfied | performpa | conditional
Indicates whether prior auth will be needed for coverage to be provided
clinical | admin | patient | conditional
Indicates whether additional documentation needs to be captured (purpose in next element)
See additional guidance in the [notes](StructureDefinition-ext-coverage-information.html#doc-needed-vs-info-needed)
withpa | withclaim | withorder | retain-doc | OTH
Indicates the reason(s) for the additional documentation that needs to be captured
Knowing what the information will be used for may influence who will fill out the form(s) and how quickly the organization will get around to filling them out
performer | location | timeframe | contract-window | detail-code | OTH
Indicates whether information about the performer, location, and/or performance date is needed to determine coverage information
See additional guidance in the [notes](StructureDefinition-ext-coverage-information.html#doc-needed-vs-info-needed) If this element is set to OTH, then there must be at least one detail element the explains the nature of the additional information needed to determine coverage, prior authorization, and/or documentation requirements. There **SHOULD** also be a doc-needed element indicating that DTR can be used to gather additional information.
Billing code(s) that must be used in the eventual claim for the coverage assertion to hold
Codes may include modifier codes, leveraging [CPT's post-coordination syntax](https://terminology.hl7.org/CPT.html)
Indicates the 'reason' for the coverage assertion
This can be used whenever the reason may not be obvious to the practitioner. E.g. prior authorization is waived because the provider is gold-carded; patient is no longer a minor and has not been registered as an adult dependent; patient has reached their limit for this type of service this year; etc. Additional standard reason codes may be introduced in the future. If no standard code applies, use text.
Indicates the 'detail' for the coverage assertion
Additional information that qualifies, describes, or provides additional guidance about coverage or documentation requirements.
Indicates the nature of the detail, which in turn provides guidance for when it should be displayed.
CRD clients **SHOULD** make both limitation and decisional details available to clinical users.
The type of detail or qualification expressed.
The binding to the old temporary code system is retained for now for backward compatibility
The detail or qualification that applies to this coverage assertion.
Additional text that qualifies/expands on the computable detail. E.g. 'Provided coverage is renewed' or 'Does not account for deductible'
If present, indicates that the determination represented here is dependent on the content, determination, and possibly execution of the referenced order(s)
For example, the authorization decision on a request for post-surgical physiotherapy might be dependent on the order for the surgery itself. If coverage for the surgery is not approved or the order for the surgery is cancelled, that might impact the decision on covering the physiotherapy.
A form to be filled out to gather more information.
If using DTR, this will be used by DTR to determine the Questionnaire packages to be returned. If empty, DTR will determine the questionnaire packages itself. If not using DTR, providing a Questionnaire url is the only way to indicate what form to complete.
Trace identifier to allow tracking the guidance in source system. This identifier can also be used to re-establish cached context information when subsequently launching DTR.
An identifier indicating that prior authorization requirements have been met
When operating under the CMS enforcement discretion, this element is a prior authorization number and can be submitted in the corresponding X12 element when submitting an eventual claim
Name, phone number, fax number, email address, website, or other contact information that can be used to ask questions/escalate issues related to a coverage assertion.
This **SHOULD** only be populated if the contact information is context-specific rather than a generic contact for the payer as a whole.
Date after which the coverage assertion would no longer be valid.
In this case, mustSupport means that if the payer knows of an expiry date, they must share it. However, if the payer never has expiry dates for their assertions, it is fine to omit.