This is a pre-release version (Ballot 1) of Coverage Requirements Discovery (CRD) R1/STU. There is no current official version.
For a full list of available versions, see the Directory of published versions .

CRD IG Home Page

This specification is currently undergoing ballot and connectathon testing. It is expected to evolve, possibly significantly, as part of that process.

Feedback is welcome and may be submitted through the FHIR gForge tracker indicating “US Da Vinci CRD” as the specification. If balloting on this IG, please submit your comments via the tracker and just reference them in your ballot submission implementation guide.

This implementation guide is dependent on other specifications. Please submit any comments you have on these base specifications as follows:

• Feedback on CDS Hooks should be posted to the CDS Hooks GitHub Issue List
• Feedback on the FHIR core specification should be submitted to the FHIR gForge tracker with "FHIR Core" as the specification.
• Feedback on the US core profiles should be submitted to the FHIR gForge tracker with "US Core" as the specification.

Individuals interested in participating in the Coverage Requirements Discovery or other HL7 Da Vinci projects can find information about Da Vinci here.

There are a few places in this implementation guide marked as ‘ToDo’. All such areas represent supplementary content such as examples, additional background or context or other non-definitional content. I.e. they do not change any of the conformance expectations on implementers. Where ToDo appears, such content will be created and included in the implementation guide prior to publication as a Standard for Trial Use.

Overview

Process of managing billing against patient insurance is a source of significant complexity and cost in the United States. Different insurance providers - and different plans within the same providers have varying expectations around documentation requirements, the determination of whether a treatment or service is necessary or appropriate, whether prior authorizations or other approvals are necessary, etc. Healthcare providers who fail to adhere to payer expectations may find that costs are not fully covered or not covered at all, resulting in increased costs for patients and/or additional visits to change ordered therapy, resulting in increased costs for everyone.

This implementation guide defines a mechanism for insurance payers to share coverage requirements with EHRs and other clinical systems at the time decisions around treatment are being made. This ensures that clinicians and administrative staff can make informed decisions and can meet the requirements of the insurance coverage the patient has.

The implementation guide provides both Personal Healthcare Information (PHI)-specific and non-PHI mechanisms as suited to the needs/privileges of the payer organization. It allows to payers to share a wide variety of information with providers in a context-sensitive manner - including:

• updated coverage information
• alternative preferred/first-line/lower-cost services/products
• documents and rules related to coverage
• forms and templates
• indications of whether prior atuthorization is required

The implementation guide is designed to allow for initial support of basic capabilities and to subsequently build new features over time.

Content and organization

The implementation guide is organized into the following sections:

• Background and use-cases describes the intent of this implementation guide and provides examples of how this specification can be used by payors
• Specification provides the technical conformance details for the specification
• Resources introduces and provides links to the FHIR STU3 and R4 profiles, search parameters and other FHIR artifacts used in this implementation guide as well as examples
• Downloads allows download of this and other specifications as well as other useful files
• Credits identifies the individuals and organizations involved in developing this implementation guide