Da Vinci Payer Data Exchange
2.1.1 - STU 2.1

Da Vinci Payer Data Exchange, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-epdx/ and changes regularly. See the Directory of published versions

## Coverage

Page standards status: Informative

Previous Page - Consent

The Coverage resource is profiled in the Da Vinci HRex IG.

NOTE: This resource is not included in the resource set returned by Payer-to-Payer exchange. The resource is used to submit coverage information to the $MemberMatch operation.

The essential fields (Must Support or Cardinality greater than 0..*) to be provided in the HRex Coverage resource are:

R4 Element | Name | Cardinality | Type
--- | --- | --- | ---
Coverage.identifier | identifier | 0..1 | Identifier
Coverage.status | status | 1..1 | code
Coverage.subscriberId | subscriberId | 0..1 | string
Coverage.beneficiary | beneficiary | 1..1 | Reference(HRex Patient Demographics Profile)
Coverage.payor | payor | 1..1 | Reference(HRex Organization Profile)

Table Definition

#### Health Plan Mapping Assistance

A collaboration of Health Plan experts have performed an evaluation of claims information and developed a mapping of data for Members to the Coverage profile. This is shown below as an assistance to implementers:

PDex Element | Must Support | Cardinality | CARIN-BB Element | CPCDS Element Mapping or Implementer Note
--- | --- | --- | --- | ---
Coverage.meta.lastUpdated |  | 0..1 | Coverage.meta.lastUpdated | [{"163":"Coverage Last Updated Date"}]
Coverage.identifier | S | 0..* | Coverage.identifier | [{"Ref (1)":"Member id"}]
Coverage.status |  | 1..1 | Coverage.status | [{"133":"Coverage status"}]
Coverage.subscriberId | S | 0..1 | Coverage.subscriberId | [{"132":"Subscriber id"}]
Coverage.beneficiary | S | 1..1 | Coverage.beneficiary | Use [{"Ref (1)":"Member id"}] to find Ratient/id Reference
Coverage.relationship |  | 0..1 | Coverage.relationship | [{"72":"Relationship to subscriber"}]
Coverage.payor | S | 1..* | Coverage.payor | [{"Ref (2) ":"Claim Payer Identifier"}
Coverage.class.value |  | 1..1 | Coverage.class.value | [{"Plan=154":"Plan Identifier"}, {"Group=134":"Group Id"}
Coverage.class.name |  | 0..1 | Coverage.class.name | [{"Plan=155":"Plan Name"}, {"Group=135":"Group Name"}

Table Definition

It is important to note a difference between Coverage information provided in the CARIN-BB IG and the PDex IG. The PDex IG Coverage expresses the current state of health plan coverage whereas the CARIN-BB Coverage is intended to express the coverage that was valid at the date of service or admission.

SubscriberId may not uniquely identify a health plan member. If beneficiary is subscriber, also set .relationship to "self".

It may, for example, identify the parent who obtains coverage for a child. Therefore, the Coverage resource may provide a combination of identifiers and point to demographic information to uniquely identify a patient/member.

Coverage.identifier MAY include a member identifier in the Coverage resource.

#### Example Coverage Resource

An example mapping of a Coverage resource is shown here:

    {
      "resourceType": "Coverage",
      "id": "9876B1",
      "text": {
        "status": "generated",
        "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the coverage</div>"
      },
      "identifier": [
        {
          "system": "http://benefitsinc.com/certificate",
          "value": "12345"
        }
      ],
      "status": "active",
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
            "code": "EHCPOL",
            "display": "extended healthcare"
          }
        ]
      },
      "policyHolder": {
        "reference": "http://benefitsinc.com/FHIR/Organization/CBI35"
      },
      "subscriber": {
        "reference": "Patient/4"
      },
      "beneficiary": {
        "reference": "Patient/4"
      },
      "dependent": "0",
      "relationship": {
        "coding": [
          {
            "code": "self"
          }
        ]
      },
      "period": {
        "start": "2011-05-23",
        "end": "2012-05-23"
      },
      "payor": [
        {
          "reference": "Organization/Payer1"
        }
      ],
      "class": [
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code": "group"
              }
            ]
          },
          "value": "CB135",
          "name": "Corporate Baker's Inc. Local #35"
        },
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code": "subgroup"
              }
            ]
          },
          "value": "123",
          "name": "Trainee Part-time Benefits"
        },
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code": "plan"
              }
            ]
          },
          "value": "B37FC",
          "name": "Full Coverage: Medical, Dental, Pharmacy, Vision, EHC"
        },
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code": "subplan"
              }
            ]
          },
          "value": "P7",
          "name": "Includes afterlife benefits"
        },
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code": "class"
              }
            ]
          },
          "value": "SILVER",
          "name": "Silver: Family Plan spouse only"
        },
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code": "subclass"
              }
            ]
          },
          "value": "Tier2",
          "name": "Low deductable, max $20 copay"
        },
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code": "sequence"
              }
            ]
          },
          "value": "9"
        },
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code": "rxid"
              }
            ]
          },
          "value": "MDF12345"
        },
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code": "rxbin"
              }
            ]
          },
          "value": "987654"
        },
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code": "rxgroup"
              }
            ]
          },
          "value": "M35PT"
        },
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code": "rxpcn"
              }
            ]
          },
          "value": "234516"
        },
        {
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                "code": "sequence"
              }
            ]
          },
          "value": "9"
        }
      ]
    }

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