Introduction

The Da Vinci Admit/Transfer/Discharge Notification Coverage Profile is based on the HRex Coverage Profile and constrains the Patient resource referenced by the Coverage.beneficiary element to be found in the same message Bundle.

Mandatory and Must Support Data Elements

The following data-elements are mandatory (i.e., data MUST be present) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Coverage must have:

1. A beneficiary
2. A reference to a payor

Each Coverage must support:

1. A business identifier
2. A subscriber id

Additional Profile specific implementation guidance:

• Note that for the admission/transfer/discharge scenario, the Coverage.beneficiary is a “reverse link” to the Patient resource and cannot be traversed from the MessageHeader within the Message Bundle. There is no mechanism to enforce profiles in a message on a reverse link except via GraphDefinition.
• The Coverage.payor references the HRex Organization Profile profile to mandate an identifier and support additional identifier types.

Examples

The following example of this profile is a freestanding resource instance which is technically invalid since the profile is defined to reference other resources within the same Da Vinci Notification Message Bundle. For examples of this profile within a bundle, see the message bundle examples which are listed on the Examples page.

• Coverage Example

• Text Summary
• Differential Table
• Snapshot Table
• Snapshot Table (Must Support)
• All

This structure is derived from HRexCoverage

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	HRexCoverage	Insurance or medical plan or a payment agreement
beneficiary		1..1	Reference(US Core Patient Profile) {b}	Plan beneficiary
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	HRexCoverage	Insurance or medical plan or a payment agreement
id	Σ	0..1	string	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..*	Identifier	Also known as Member identifier
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required)
type	Σ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred)
policyHolder	Σ	0..1	Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)	Owner of the policy
subscriber	Σ	0..1	Reference(US Core Patient Profile)	Subscriber to the policy
subscriberId	SΣ	0..1	string	Subscriber ID
beneficiary	SΣ	1..1	Reference(US Core Patient Profile) {b}	Plan beneficiary
dependent	Σ	0..1	string	Dependent number
relationship		0..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period	Σ	0..1	Period	Coverage start and end dates
payor	SΣ	1..*	Reference(HRex Organization Profile)	Issuer of the policy
class		0..*	BackboneElement	Additional coverage classifications
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible)
value	Σ	1..1	string	Value associated with the type
name	Σ	0..1	string	Human readable description of the type and value
order	Σ	0..1	positiveInt	Relative order of the coverage
network	Σ	0..1	string	Insurer network
costToBeneficiary		0..*	BackboneElement	Patient payments for services/products
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	0..1	CodeableConcept	Cost category Binding: CoverageCopayTypeCodes (extensible)
value[x]	Σ	1..1		The amount or percentage due from the beneficiary
valueQuantity			Quantity(SimpleQuantity)
valueMoney			Money
exception		0..*	BackboneElement	Exceptions for patient payments
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Exception category Binding: ExampleCoverageFinancialExceptionCodes (example)
period	Σ	0..1	Period	The effective period of the exception
subrogation		0..1	boolean	Reimbursement to insurer
contract		0..*	Reference(Contract)	Contract details
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	HRexCoverage	Insurance or medical plan or a payment agreement
identifier	Σ	0..*	Identifier	Also known as Member identifier
subscriberId	Σ	0..1	string	Subscriber ID
beneficiary	Σ	1..1	Reference(US Core Patient Profile) {b}	Plan beneficiary
payor	Σ	1..*	Reference(HRex Organization Profile)	Issuer of the policy
Documentation for this format

This structure is derived from HRexCoverage

Summary

Structures

This structure refers to these other structures:

• http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient

Differential View

This structure is derived from HRexCoverage

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	HRexCoverage	Insurance or medical plan or a payment agreement
beneficiary		1..1	Reference(US Core Patient Profile) {b}	Plan beneficiary
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	HRexCoverage	Insurance or medical plan or a payment agreement
id	Σ	0..1	string	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..*	Identifier	Also known as Member identifier
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required)
type	Σ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred)
policyHolder	Σ	0..1	Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)	Owner of the policy
subscriber	Σ	0..1	Reference(US Core Patient Profile)	Subscriber to the policy
subscriberId	SΣ	0..1	string	Subscriber ID
beneficiary	SΣ	1..1	Reference(US Core Patient Profile) {b}	Plan beneficiary
dependent	Σ	0..1	string	Dependent number
relationship		0..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period	Σ	0..1	Period	Coverage start and end dates
payor	SΣ	1..*	Reference(HRex Organization Profile)	Issuer of the policy
class		0..*	BackboneElement	Additional coverage classifications
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible)
value	Σ	1..1	string	Value associated with the type
name	Σ	0..1	string	Human readable description of the type and value
order	Σ	0..1	positiveInt	Relative order of the coverage
network	Σ	0..1	string	Insurer network
costToBeneficiary		0..*	BackboneElement	Patient payments for services/products
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	0..1	CodeableConcept	Cost category Binding: CoverageCopayTypeCodes (extensible)
value[x]	Σ	1..1		The amount or percentage due from the beneficiary
valueQuantity			Quantity(SimpleQuantity)
valueMoney			Money
exception		0..*	BackboneElement	Exceptions for patient payments
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Exception category Binding: ExampleCoverageFinancialExceptionCodes (example)
period	Σ	0..1	Period	The effective period of the exception
subrogation		0..1	boolean	Reimbursement to insurer
contract		0..*	Reference(Contract)	Contract details
Documentation for this format