Da Vinci Prior Authorization Support (PAS) FHIR IG
2.0.1 - STU 2 United States of America flag

Da Vinci Prior Authorization Support (PAS) FHIR IG, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pas/ and changes regularly. See the Directory of published versions

Resource Profile: PAS Coverage

Official URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage Version: 2.0.1
Standards status: Trial-use Maturity Level: 3 Computable Name: PASCoverage

PAS constraints on Coverage resource mandating support for insurance elements relevant to the prior authorization request

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage Coverage
... identifier S0..*IdentifierBusiness Identifier for the coverage
... status S1..1codeactive | cancelled | draft | entered-in-error
Required Pattern: active
... subscriber S0..1Reference(PAS Subscriber Patient)Subscriber to the policy
... beneficiary S1..1Reference(PAS Beneficiary Patient)Plan beneficiary
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
.... Slices for coding 0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code S0..1CodingCode defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

... payor S1..*Reference(PAS Insurer Organization)Issuer of the policy

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Coverage.relationship.coding:X12Coderequiredhttps://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierBusiness Identifier for the coverage
... subscriber SΣ0..1Reference(PAS Subscriber Patient)Subscriber to the policy
... subscriberId SΣ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(PAS Beneficiary Patient)Plan beneficiary
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

.... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code SΣ0..1CodingCode defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


... payor SΣ1..*Reference(PAS Insurer Organization)Issuer of the policy

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Coverage.statusrequiredPattern: active
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.relationship.coding:X12Coderequiredhttps://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierBusiness Identifier for the coverage
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... type Σ0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.

... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber SΣ0..1Reference(PAS Subscriber Patient)Subscriber to the policy
... subscriberId SΣ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(PAS Beneficiary Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code SΣ0..1CodingCode defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... text Σ0..1stringPlain text representation of the concept
... period Σ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(PAS Insurer Organization)Issuer of the policy
... class 0..*BackboneElementAdditional coverage classifications
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

.... value Σ1..1stringValue associated with the type
.... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.statusrequiredPattern: active
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.relationship.coding:X12Coderequiredhttps://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
Coverage.class.typeextensibleCoverageClassCodes
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

This structure is derived from Coverage

Summary

Must-Support: 8 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Coverage.relationship.coding is sliced based on the value of value:$this

Maturity: 3

Differential View

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage Coverage
... identifier S0..*IdentifierBusiness Identifier for the coverage
... status S1..1codeactive | cancelled | draft | entered-in-error
Required Pattern: active
... subscriber S0..1Reference(PAS Subscriber Patient)Subscriber to the policy
... beneficiary S1..1Reference(PAS Beneficiary Patient)Plan beneficiary
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
.... Slices for coding 0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code S0..1CodingCode defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

... payor S1..*Reference(PAS Insurer Organization)Issuer of the policy

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Coverage.relationship.coding:X12Coderequiredhttps://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierBusiness Identifier for the coverage
... subscriber SΣ0..1Reference(PAS Subscriber Patient)Subscriber to the policy
... subscriberId SΣ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(PAS Beneficiary Patient)Plan beneficiary
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

.... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code SΣ0..1CodingCode defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


... payor SΣ1..*Reference(PAS Insurer Organization)Issuer of the policy

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Coverage.statusrequiredPattern: active
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.relationship.coding:X12Coderequiredhttps://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierBusiness Identifier for the coverage
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... type Σ0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.

... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber SΣ0..1Reference(PAS Subscriber Patient)Subscriber to the policy
... subscriberId SΣ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(PAS Beneficiary Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code SΣ0..1CodingCode defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... text Σ0..1stringPlain text representation of the concept
... period Σ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(PAS Insurer Organization)Issuer of the policy
... class 0..*BackboneElementAdditional coverage classifications
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

.... value Σ1..1stringValue associated with the type
.... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.statusrequiredPattern: active
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.relationship.coding:X12Coderequiredhttps://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
Coverage.class.typeextensibleCoverageClassCodes
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

This structure is derived from Coverage

Summary

Must-Support: 8 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Coverage.relationship.coding is sliced based on the value of value:$this

Maturity: 3

 

Other representations of profile: CSV, Excel, Schematron