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
| Page standards status: Trial-use | Maturity Level: 4 |
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<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. 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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. 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</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 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</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>
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<display value="Concurrent review"/>
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value="Additional payer-defined documentation will be required prior to claim payment. Value should be a boolean."/>
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<definition
value="Payer-defined appropriate use process must be invoked to determine coverage. Value should be a boolean."/>
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<display value="Other details"/>
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<display value="Instructions"/>
<definition
value="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.)"/>
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<display value="Card Type (abstract)"/>
<definition value="A collector for different profiles on CDS Hooks card"/>
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<display value="Unsolicited Determination"/>
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<display value="Insurance"/>
<definition
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<display value="Limits"/>
<definition
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<display value="Optional Therapy Alternatives"/>
<definition
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<display value="Required Therapy Alternatives"/>
<definition
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<display value="Clinical Reminder"/>
<definition
value="Reminders that a patient is due for certain screening or other therapy (based on payer recorded date of last intervention)"/>
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<concept>
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<display value="Duplicate Therapy"/>
<definition
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<display value="Contraindication"/>
<definition
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<definition value="Categories related to how the system behaves"/>
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<code value="ui"/>
<display value="User Interface"/>
<definition
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<display value="UI Accessibility"/>
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<display value="UI Consistency"/>
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<display value="UI Usability"/>
<definition
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<code value="safety"/>
<display value="Safety"/>
<definition
value="Requirements that ensure that system operation does not negatively impact the wellbeing of people or assets"/>
</concept>
<concept>
<code value="performance"/>
<display value="Performance/Scalability"/>
<definition
value="Requirements that deal with timeliness of processing and/or responsiveness under differing levels of load/volume"/>
</concept>
</concept>
</concept>
<concept>
<code value="source"/>
<display value="Source"/>
<definition
value="Categories related to where the requirement came from"/>
<property>
<code value="abstract"/>
<valueBoolean value="true"/>
</property>
<concept>
<code value="user"/>
<display value="User Requirements"/>
<definition
value="Requirements originating from the community of individuals expected to use the system/solution"/>
</concept>
<concept>
<code value="legal"/>
<display value="Legal Requirements"/>
<definition value="Requirements originating from regulation or law"/>
</concept>
<concept>
<code value="design"/>
<display value="Design Decisions"/>
<definition
value="Requirements documenting decisions made in the design of the solution"/>
</concept>
</concept>
</concept>
</CodeSystem>