Da Vinci - Coverage Requirements Discovery
2.2.0 - STU 2.2 United States of America flag

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 2.2.0 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

: CRD Temporary Codes

Page standards status: Trial-use Maturity Level: 4

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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 "temp"] ; # 
  fhir:language [ fhir:v "en"] ; # 
  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 temp</b></p><a name=\"temp\"> </a><a name=\"hctemp\"> </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://hl7.org/fhir/us/davinci-crd/CodeSystem/temp</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\">gold-card<a name=\"temp-gold-card\"> </a></td><td>Gold card</td><td>Ordering Practitioner has been granted 'gold card' status with this payer/coverage type.</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">no-member-found<a name=\"temp-no-member-found\"> </a></td><td>Member not found</td><td>The server was unable to find a matching member or was unable to resolve to a single member, so no coverage information can be provided.</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">no-active-coverage<a name=\"temp-no-active-coverage\"> </a></td><td>Coverage not active</td><td>The referenced coverage for the member was found but is not in force during the relevant time period for which the coverage is being evaluated.</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">coverage-not-found<a name=\"temp-coverage-not-found\"> </a></td><td>Coverage not found</td><td>The payer is not available to resolve the provided coverage information to an existing coverage record, or it is not specific enough to resolve to a single coverage.</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">auth-out-network<a name=\"temp-auth-out-network\"> </a></td><td>Authorization needed out-of-network</td><td>Authorization is necessary if out-of-network.</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">technical<a name=\"temp-technical\"> </a></td><td>Technical issues</td><td>The server encountered technical issues either internally or with their interaction with the client.  It is possible these issues are transient and later calls might provide more information.</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">_limitation<a name=\"temp-_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=\"temp-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=\"temp-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=\"temp-_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=\"temp-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=\"temp-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=\"temp-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=\"temp-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=\"temp-_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=\"temp-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=\"temp-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><tr><td>1</td><td style=\"white-space:nowrap\">_cardType<a name=\"temp-_cardType\"> </a></td><td>Card Type (abstract)</td><td>A collector for different profiles on CDS Hooks card</td><td>true</td></tr><tr><td>2</td><td style=\"white-space:nowrap\">  coverage-info<a name=\"temp-coverage-info\"> </a></td><td>Coverage Information</td><td>Information related to the patient's coverage, including whether a service is covered, requires prior authorization, is approved without seeking prior authorization, and/or requires additional documentation or data collection</td><td/></tr><tr><td>3</td><td style=\"white-space:nowrap\">    unsolicited-determ<a name=\"temp-unsolicited-determ\"> </a></td><td>Unsolicited Determination</td><td>An unsolicited approval of the service as having prior authorization requirements met without a formal submission of a prior authorization request</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">  claim<a name=\"temp-claim\"> </a></td><td>Claim</td><td>Information about what steps need to be taken to submit a claim for the service</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">  insurance<a name=\"temp-insurance\"> </a></td><td>Insurance</td><td>Allows a provider to update the patient's coverage information with additional details from the payer (e.g. expiry date, coverage extensions)</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">  limits<a name=\"temp-limits\"> </a></td><td>Limits</td><td>Messages warning about the patient approaching or exceeding their limits for a particular type of coverage or expiry date for coverage in general</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">  network<a name=\"temp-network\"> </a></td><td>Network</td><td>Providing information about in-network providers that could deliver the order (or in-network alternatives for an order directed out-of-network)</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">  appropriate-use<a name=\"temp-appropriate-use\"> </a></td><td>Appropriate Use</td><td>Guidance on whether appropriate-use documentation is needed</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">  cost<a name=\"temp-cost\"> </a></td><td>Cost</td><td>What is the anticipated cost to the patient based on their coverage</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">  therapy-alternatives-opt<a name=\"temp-therapy-alternatives-opt\"> </a></td><td>Optional Therapy Alternatives</td><td>Are there alternative therapies that have better coverage and/or are lower-cost for the patient</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">  therapy-alternatives-req<a name=\"temp-therapy-alternatives-req\"> </a></td><td>Required Therapy Alternatives</td><td>Are there alternative therapies that must be tried first prior to coverage being available for the proposed therapy</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">  clinical-reminder<a name=\"temp-clinical-reminder\"> </a></td><td>Clinical Reminder</td><td>Reminders that a patient is due for certain screening or other therapy (based on payer recorded date of last intervention)</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">  duplicate-therapy<a name=\"temp-duplicate-therapy\"> </a></td><td>Duplicate Therapy</td><td>Notice that the proposed intervention has already recently occurred with a different provider when that information is not already available in the provider system</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">  contraindication<a name=\"temp-contraindication\"> </a></td><td>Contraindication</td><td>Notice that the proposed intervention may be contraindicated based on information the payer has in their record that the provider does not have in theirs</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">  guideline<a name=\"temp-guideline\"> </a></td><td>Guideline</td><td>Indication that there is a guideline available for the proposed therapy (with an option to view)</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">  off-guideline<a name=\"temp-off-guideline\"> </a></td><td>Off Guideline</td><td>Notice that the proposed therapy may be contrary to best-practice guidelines, typically with an option to view the relevant guideline</td><td/></tr><tr><td>1</td><td style=\"white-space:nowrap\">_reqcat<a name=\"temp-_reqcat\"> </a></td><td>Requirements Categories</td><td>Codes that help to categorize requirements statements</td><td>true</td></tr><tr><td>2</td><td style=\"white-space:nowrap\">  behavioral<a name=\"temp-behavioral\"> </a></td><td>Behavioral</td><td>Categories related to how the system behaves</td><td>true</td></tr><tr><td>3</td><td style=\"white-space:nowrap\">    business<a name=\"temp-business\"> </a></td><td>Business</td><td>Requirements relating to the business operations of the entities responsible for a system</td><td/></tr><tr><td>3</td><td style=\"white-space:nowrap\">    functional<a name=\"temp-functional\"> </a></td><td>Functional</td><td>Requirements related to what the system does (inputs turned into outputs)</td><td/></tr><tr><td>4</td><td style=\"white-space:nowrap\">      exchange<a name=\"temp-exchange\"> </a></td><td>Exchange</td><td>Requirements relating to when, how, or what data is exchanged with other systems</td><td/></tr><tr><td>4</td><td style=\"white-space:nowrap\">      processing<a name=\"temp-processing\"> </a></td><td>Processing</td><td>Requirements related to how data must be analyzed, transformed, considered, or otherwise used within a system</td><td/></tr><tr><td>4</td><td style=\"white-space:nowrap\">      storage<a name=\"temp-storage\"> </a></td><td>Storage</td><td>Requirements related to if or how data is persisted in a system</td><td/></tr><tr><td>3</td><td style=\"white-space:nowrap\">    non-functional<a name=\"temp-non-functional\"> </a></td><td>Non-functional</td><td>Requirements related to how the system accomplishes functional requirements</td><td/></tr><tr><td>4</td><td style=\"white-space:nowrap\">      availability<a name=\"temp-availability\"> </a></td><td>Availability</td><td>Requirements related to how and when a system needs to be reachable and useable</td><td/></tr><tr><td>4</td><td style=\"white-space:nowrap\">      ui<a name=\"temp-ui\"> </a></td><td>User Interface</td><td>Requirements related to how information is collected from and exposed to humans (or animals)</td><td/></tr><tr><td>5</td><td style=\"white-space:nowrap\">        ui-accessibility<a name=\"temp-ui-accessibility\"> </a></td><td>UI Accessibility</td><td>Requirements around user interface that ensure a satisfactory experience for users from different backgrounds or with varying physical, cognitive, and/or sensory abilities</td><td/></tr><tr><td>5</td><td style=\"white-space:nowrap\">        ui-consistency<a name=\"temp-ui-consistency\"> </a></td><td>UI Consistency</td><td>Requirements around ensuring that different implementations have sufficiently aligned appearance and mechanisms of interaction</td><td/></tr><tr><td>5</td><td style=\"white-space:nowrap\">        ui-usability<a name=\"temp-ui-usability\"> </a></td><td>UI Usability</td><td>Requirements related to the intuitiveness, simplicity, and ease-of-use of a user-interface</td><td/></tr><tr><td>4</td><td style=\"white-space:nowrap\">      security<a name=\"temp-security\"> </a></td><td>Security/Privacy</td><td>Requirements that ensure that data is appropriately protected from threats and respects rules around what parties are permitted to access or manipulate</td><td/></tr><tr><td>4</td><td style=\"white-space:nowrap\">      safety<a name=\"temp-safety\"> </a></td><td>Safety</td><td>Requirements that ensure that system operation does not negatively impact the wellbeing of people or assets</td><td/></tr><tr><td>4</td><td style=\"white-space:nowrap\">      performance<a name=\"temp-performance\"> </a></td><td>Performance/Scalability</td><td>Requirements that deal with timeliness of processing and/or responsiveness under differing levels of load/volume</td><td/></tr><tr><td>2</td><td style=\"white-space:nowrap\">  source<a name=\"temp-source\"> </a></td><td>Source</td><td>Categories related to where the requirement came from</td><td>true</td></tr><tr><td>3</td><td style=\"white-space:nowrap\">    user<a name=\"temp-user\"> </a></td><td>User Requirements</td><td>Requirements originating from the community of individuals expected to use the system/solution</td><td/></tr><tr><td>3</td><td style=\"white-space:nowrap\">    legal<a name=\"temp-legal\"> </a></td><td>Legal Requirements</td><td>Requirements originating from regulation or law</td><td/></tr><tr><td>3</td><td style=\"white-space:nowrap\">    design<a name=\"temp-design\"> </a></td><td>Design Decisions</td><td>Requirements documenting decisions made in the design of the solution</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 4 ;
      ( fhir:extension [
fhir:url [
fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom>         ] ;
fhir:value [
a fhir:Canonical ;
fhir:v "http://hl7.org/fhir/us/davinci-crd/ImplementationGuide/davinci-crd"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-crd/ImplementationGuide/davinci-crd>         ]       ] )     ]
  ] [
fhir:url [
fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status>     ] ;
fhir:value [
a fhir:Code ;
fhir:v "trial-use" ;
      ( fhir:extension [
fhir:url [
fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom>         ] ;
fhir:value [
a fhir:Canonical ;
fhir:v "http://hl7.org/fhir/us/davinci-crd/ImplementationGuide/davinci-crd"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-crd/ImplementationGuide/davinci-crd>         ]       ] )     ]
  ] ) ; # 
  fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp>
  ] ; # 
  fhir:identifier ( [
fhir:system [
fhir:v "urn:ietf:rfc:3986"^^xsd:anyURI ;
fhir:l <urn:ietf:rfc:3986>     ] ;
fhir:value [ fhir:v "urn:oid:2.16.840.1.113883.4.642.40.18.16.1" ]
  ] ) ; # 
  fhir:version [ fhir:v "2.2.0"] ; # 
  fhir:name [ fhir:v "CRDTempCodes"] ; # 
  fhir:title [ fhir:v "CRD Temporary Codes"] ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:experimental [ fhir:v false] ; # 
  fhir:date [ fhir:v "2026-03-04T04:00:26+00:00"^^xsd:dateTime] ; # 
  fhir:publisher [ fhir:v "HL7 International / Financial Management"] ; # 
  fhir:contact ( [
    ( fhir:telecom [
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://www.hl7.org/Special/committees/fm" ]     ] )
  ] ) ; # 
  fhir:description [ fhir:v "Codes temporarily defined as part of the CRD implementation guide.  These will eventually migrate into an officially maintained terminology (likely either SNOMED CT or HL7's UTG code systems)."] ; # 
  fhir:jurisdiction ( [
    ( fhir:coding [
fhir:system [
fhir:v "urn:iso:std:iso:3166"^^xsd:anyURI ;
fhir:l <urn:iso:std:iso:3166>       ] ;
fhir:code [ fhir:v "US" ]     ] )
  ] ) ; # 
  fhir:caseSensitive [ fhir:v true] ; # 
  fhir:hierarchyMeaning [ fhir:v "is-a"] ; # 
  fhir:content [ fhir:v "complete"] ; # 
  fhir:count [ fhir:v "53"^^xsd:nonNegativeInteger] ; # 
  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 "gold-card" ] ;
fhir:display [ fhir:v "Gold card" ] ;
fhir:definition [ fhir:v "Ordering Practitioner has been granted 'gold card' status with this payer/coverage type." ]
  ] [
fhir:code [ fhir:v "no-member-found" ] ;
fhir:display [ fhir:v "Member not found" ] ;
fhir:definition [ fhir:v "The server was unable to find a matching member or was unable to resolve to a single member, so no coverage information can be provided." ]
  ] [
fhir:code [ fhir:v "no-active-coverage" ] ;
fhir:display [ fhir:v "Coverage not active" ] ;
fhir:definition [ fhir:v "The referenced coverage for the member was found but is not in force during the relevant time period for which the coverage is being evaluated." ]
  ] [
fhir:code [ fhir:v "coverage-not-found" ] ;
fhir:display [ fhir:v "Coverage not found" ] ;
fhir:definition [ fhir:v "The payer is not available to resolve the provided coverage information to an existing coverage record, or it is not specific enough to resolve to a single coverage." ]
  ] [
fhir:code [ fhir:v "auth-out-network" ] ;
fhir:display [ fhir:v "Authorization needed out-of-network" ] ;
fhir:definition [ fhir:v "Authorization is necessary if out-of-network." ]
  ] [
fhir:code [ fhir:v "technical" ] ;
fhir:display [ fhir:v "Technical issues" ] ;
fhir:definition [ fhir:v "The server encountered technical issues either internally or with their interaction with the client.  It is possible these issues are transient and later calls might provide more information." ]
  ] [
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.)" ]
  ] [
fhir:code [ fhir:v "_cardType" ] ;
fhir:display [ fhir:v "Card Type (abstract)" ] ;
fhir:definition [ fhir:v "A collector for different profiles on CDS Hooks card" ] ;
    ( fhir:property [
fhir:code [ fhir:v "abstract" ] ;
fhir:value [
a fhir:Boolean ;
fhir:v true       ]     ] ) ;
    ( fhir:concept [
fhir:code [ fhir:v "coverage-info" ] ;
fhir:display [ fhir:v "Coverage Information" ] ;
fhir:definition [ fhir:v "Information related to the patient's coverage, including whether a service is covered, requires prior authorization, is approved without seeking prior authorization, and/or requires additional documentation or data collection" ] ;
      ( fhir:concept [
fhir:code [ fhir:v "unsolicited-determ" ] ;
fhir:display [ fhir:v "Unsolicited Determination" ] ;
fhir:definition [ fhir:v "An unsolicited approval of the service as having prior authorization requirements met without a formal submission of a prior authorization request" ]       ] )     ] [
fhir:code [ fhir:v "claim" ] ;
fhir:display [ fhir:v "Claim" ] ;
fhir:definition [ fhir:v "Information about what steps need to be taken to submit a claim for the service" ]     ] [
fhir:code [ fhir:v "insurance" ] ;
fhir:display [ fhir:v "Insurance" ] ;
fhir:definition [ fhir:v "Allows a provider to update the patient's coverage information with additional details from the payer (e.g. expiry date, coverage extensions)" ]     ] [
fhir:code [ fhir:v "limits" ] ;
fhir:display [ fhir:v "Limits" ] ;
fhir:definition [ fhir:v "Messages warning about the patient approaching or exceeding their limits for a particular type of coverage or expiry date for coverage in general" ]     ] [
fhir:code [ fhir:v "network" ] ;
fhir:display [ fhir:v "Network" ] ;
fhir:definition [ fhir:v "Providing information about in-network providers that could deliver the order (or in-network alternatives for an order directed out-of-network)" ]     ] [
fhir:code [ fhir:v "appropriate-use" ] ;
fhir:display [ fhir:v "Appropriate Use" ] ;
fhir:definition [ fhir:v "Guidance on whether appropriate-use documentation is needed" ]     ] [
fhir:code [ fhir:v "cost" ] ;
fhir:display [ fhir:v "Cost" ] ;
fhir:definition [ fhir:v "What is the anticipated cost to the patient based on their coverage" ]     ] [
fhir:code [ fhir:v "therapy-alternatives-opt" ] ;
fhir:display [ fhir:v "Optional Therapy Alternatives" ] ;
fhir:definition [ fhir:v "Are there alternative therapies that have better coverage and/or are lower-cost for the patient" ]     ] [
fhir:code [ fhir:v "therapy-alternatives-req" ] ;
fhir:display [ fhir:v "Required Therapy Alternatives" ] ;
fhir:definition [ fhir:v "Are there alternative therapies that must be tried first prior to coverage being available for the proposed therapy" ]     ] [
fhir:code [ fhir:v "clinical-reminder" ] ;
fhir:display [ fhir:v "Clinical Reminder" ] ;
fhir:definition [ fhir:v "Reminders that a patient is due for certain screening or other therapy (based on payer recorded date of last intervention)" ]     ] [
fhir:code [ fhir:v "duplicate-therapy" ] ;
fhir:display [ fhir:v "Duplicate Therapy" ] ;
fhir:definition [ fhir:v "Notice that the proposed intervention has already recently occurred with a different provider when that information is not already available in the provider system" ]     ] [
fhir:code [ fhir:v "contraindication" ] ;
fhir:display [ fhir:v "Contraindication" ] ;
fhir:definition [ fhir:v "Notice that the proposed intervention may be contraindicated based on information the payer has in their record that the provider does not have in theirs" ]     ] [
fhir:code [ fhir:v "guideline" ] ;
fhir:display [ fhir:v "Guideline" ] ;
fhir:definition [ fhir:v "Indication that there is a guideline available for the proposed therapy (with an option to view)" ]     ] [
fhir:code [ fhir:v "off-guideline" ] ;
fhir:display [ fhir:v "Off Guideline" ] ;
fhir:definition [ fhir:v "Notice that the proposed therapy may be contrary to best-practice guidelines, typically with an option to view the relevant guideline" ]     ] )
  ] [
fhir:code [ fhir:v "_reqcat" ] ;
fhir:display [ fhir:v "Requirements Categories" ] ;
fhir:definition [ fhir:v "Codes that help to categorize requirements statements" ] ;
    ( fhir:property [
fhir:code [ fhir:v "abstract" ] ;
fhir:value [
a fhir:Boolean ;
fhir:v true       ]     ] ) ;
    ( fhir:concept [
fhir:code [ fhir:v "behavioral" ] ;
fhir:display [ fhir:v "Behavioral" ] ;
fhir:definition [ fhir:v "Categories related to how the system behaves" ] ;
      ( fhir:property [
fhir:code [ fhir:v "abstract" ] ;
fhir:value [
a fhir:Boolean ;
fhir:v true         ]       ] ) ;
      ( fhir:concept [
fhir:code [ fhir:v "business" ] ;
fhir:display [ fhir:v "Business" ] ;
fhir:definition [ fhir:v "Requirements relating to the business operations of the entities responsible for a system" ]       ] [
fhir:code [ fhir:v "functional" ] ;
fhir:display [ fhir:v "Functional" ] ;
fhir:definition [ fhir:v "Requirements related to what the system does (inputs turned into outputs)" ] ;
        ( fhir:concept [
fhir:code [ fhir:v "exchange" ] ;
fhir:display [ fhir:v "Exchange" ] ;
fhir:definition [ fhir:v "Requirements relating to when, how, or what data is exchanged with other systems" ]         ] [
fhir:code [ fhir:v "processing" ] ;
fhir:display [ fhir:v "Processing" ] ;
fhir:definition [ fhir:v "Requirements related to how data must be analyzed, transformed, considered, or otherwise used within a system" ]         ] [
fhir:code [ fhir:v "storage" ] ;
fhir:display [ fhir:v "Storage" ] ;
fhir:definition [ fhir:v "Requirements related to if or how data is persisted in a system" ]         ] )       ] [
fhir:code [ fhir:v "non-functional" ] ;
fhir:display [ fhir:v "Non-functional" ] ;
fhir:definition [ fhir:v "Requirements related to how the system accomplishes functional requirements" ] ;
        ( fhir:concept [
fhir:code [ fhir:v "availability" ] ;
fhir:display [ fhir:v "Availability" ] ;
fhir:definition [ fhir:v "Requirements related to how and when a system needs to be reachable and useable" ]         ] [
fhir:code [ fhir:v "ui" ] ;
fhir:display [ fhir:v "User Interface" ] ;
fhir:definition [ fhir:v "Requirements related to how information is collected from and exposed to humans (or animals)" ] ;
          ( fhir:concept [
fhir:code [ fhir:v "ui-accessibility" ] ;
fhir:display [ fhir:v "UI Accessibility" ] ;
fhir:definition [ fhir:v "Requirements around user interface that ensure a satisfactory experience for users from different backgrounds or with varying physical, cognitive, and/or sensory abilities" ]           ] [
fhir:code [ fhir:v "ui-consistency" ] ;
fhir:display [ fhir:v "UI Consistency" ] ;
fhir:definition [ fhir:v "Requirements around ensuring that different implementations have sufficiently aligned appearance and mechanisms of interaction" ]           ] [
fhir:code [ fhir:v "ui-usability" ] ;
fhir:display [ fhir:v "UI Usability" ] ;
fhir:definition [ fhir:v "Requirements related to the intuitiveness, simplicity, and ease-of-use of a user-interface" ]           ] )         ] [
fhir:code [ fhir:v "security" ] ;
fhir:display [ fhir:v "Security/Privacy" ] ;
fhir:definition [ fhir:v "Requirements that ensure that data is appropriately protected from threats and respects rules around what parties are permitted to access or manipulate" ]         ] [
fhir:code [ fhir:v "safety" ] ;
fhir:display [ fhir:v "Safety" ] ;
fhir:definition [ fhir:v "Requirements that ensure that system operation does not negatively impact the wellbeing of people or assets" ]         ] [
fhir:code [ fhir:v "performance" ] ;
fhir:display [ fhir:v "Performance/Scalability" ] ;
fhir:definition [ fhir:v "Requirements that deal with timeliness of processing and/or responsiveness under differing levels of load/volume" ]         ] )       ] )     ] [
fhir:code [ fhir:v "source" ] ;
fhir:display [ fhir:v "Source" ] ;
fhir:definition [ fhir:v "Categories related to where the requirement came from" ] ;
      ( fhir:property [
fhir:code [ fhir:v "abstract" ] ;
fhir:value [
a fhir:Boolean ;
fhir:v true         ]       ] ) ;
      ( fhir:concept [
fhir:code [ fhir:v "user" ] ;
fhir:display [ fhir:v "User Requirements" ] ;
fhir:definition [ fhir:v "Requirements originating from the community of individuals expected to use the system/solution" ]       ] [
fhir:code [ fhir:v "legal" ] ;
fhir:display [ fhir:v "Legal Requirements" ] ;
fhir:definition [ fhir:v "Requirements originating from regulation or law" ]       ] [
fhir:code [ fhir:v "design" ] ;
fhir:display [ fhir:v "Design Decisions" ] ;
fhir:definition [ fhir:v "Requirements documenting decisions made in the design of the solution" ]       ] )     ] )
  ] ) . #