Da Vinci - Coverage Requirements Discovery
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This page is part of the Da Vinci Coverage Requirements Discovery (CRD) FHIR IG (v2.1.0-preview: STU 2.1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.1. For a full list of available versions, see the Directory of published versions

: CRD Coverage Detail Codes Value Set - JSON Representation

Page standards status: Trial-use Maturity Level: 2

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{
  "resourceType" : "ValueSet",
  "id" : "coverageDetail",
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ValueSet coverageDetail</b></p><a name=\"coverageDetail\"> </a><a name=\"hccoverageDetail\"> </a><a name=\"coverageDetail-en-US\"> </a><ul><li>Include these codes as defined in <a href=\"CodeSystem-temp.html\"><code>http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp</code></a><table class=\"none\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td><a href=\"CodeSystem-temp.html#temp-allowed-quantity\">allowed-quantity</a></td><td style=\"color: #cccccc\">Maximum quantity</td><td>Indicates limitations on the number of services/products allowed (possibly per time period).  Value should be a Quantity</td></tr><tr><td><a href=\"CodeSystem-temp.html#temp-allowed-period\">allowed-period</a></td><td style=\"color: #cccccc\">Maximum allowed period</td><td>Indicates the maximum period of time that can be covered in a single order.  Value should be a Period</td></tr><tr><td><a href=\"CodeSystem-temp.html#temp-in-network-copay\">in-network-copay</a></td><td style=\"color: #cccccc\">Copay for in-network</td><td>Indicates a percentage co-pay to expect if delivered in-network.  Value should be a Quantity.</td></tr><tr><td><a href=\"CodeSystem-temp.html#temp-out-network-copay\">out-network-copay</a></td><td style=\"color: #cccccc\">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></tr><tr><td><a href=\"CodeSystem-temp.html#temp-auth-out-network-only\">auth-out-network-only</a></td><td style=\"color: #cccccc\">Authorization out-of-network only</td><td>Authorization is only necessary if out-of-network.  Value should be a boolean.</td></tr><tr><td><a href=\"CodeSystem-temp.html#temp-concurrent-review\">concurrent-review</a></td><td style=\"color: #cccccc\">Concurrent review</td><td>Additional payer-defined documentation will be required prior to claim payment.  Value should be a boolean.</td></tr><tr><td><a href=\"CodeSystem-temp.html#temp-appropriate-use-needed\">appropriate-use-needed</a></td><td style=\"color: #cccccc\">Appropriate use</td><td>Payer-defined appropriate use process must be invoked to determine coverage.  Value should be a boolean.</td></tr><tr><td><a href=\"CodeSystem-temp.html#temp-policy-link\">policy-link</a></td><td style=\"color: #cccccc\">Policy Link</td><td>A URL pointing to the specific portion of a payer policy, coverage agreement or similar authoritative document that provides a portion of the basis for the decision documented in the coverage-information.  Value should be a url.</td></tr><tr><td><a href=\"CodeSystem-temp.html#temp-instructions\">instructions</a></td><td style=\"color: #cccccc\">Instructions</td><td>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.</td></tr><tr><td><a href=\"CodeSystem-temp.html#temp-instructions-clinical\">instructions-clinical</a></td><td style=\"color: #cccccc\">Clinical instructions</td><td>Instructions specifically intended for the use of clinical (rather than administrative staff)</td></tr><tr><td><a href=\"CodeSystem-temp.html#temp-instructions-admin\">instructions-admin</a></td><td style=\"color: #cccccc\">Administrative Instructions</td><td>Instructions specifically intended for the use of administrative (rather than clinical staff)</td></tr></table></li></ul></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode" : "fm"
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
      "valueInteger" : 2,
      "_valueInteger" : {
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical" : "http://hl7.org/fhir/us/davinci-crd/ImplementationGuide/davinci-crd"
          }
        ]
      }
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
      "valueCode" : "trial-use",
      "_valueCode" : {
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical" : "http://hl7.org/fhir/us/davinci-crd/ImplementationGuide/davinci-crd"
          }
        ]
      }
    }
  ],
  "url" : "http://hl7.org/fhir/us/davinci-crd/ValueSet/coverageDetail",
  "version" : "2.1.0-preview",
  "name" : "CRDCoverageDetailCodes",
  "title" : "CRD Coverage Detail Codes Value Set",
  "status" : "active",
  "experimental" : false,
  "date" : "2024-09-26T14:59:51-04:00",
  "publisher" : "HL7 International / Financial Management",
  "contact" : [
    {
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/fm"
        }
      ]
    }
  ],
  "description" : "Codes for name-value-pair details on a coverage assertion",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "urn:iso:std:iso:3166",
          "code" : "US"
        }
      ]
    }
  ],
  "compose" : {
    "include" : [
      {
        "system" : "http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp",
        "concept" : [
          {
            "code" : "allowed-quantity"
          },
          {
            "code" : "allowed-period"
          },
          {
            "code" : "in-network-copay"
          },
          {
            "code" : "out-network-copay"
          },
          {
            "code" : "auth-out-network-only"
          },
          {
            "code" : "concurrent-review"
          },
          {
            "code" : "appropriate-use-needed"
          },
          {
            "code" : "policy-link"
          },
          {
            "code" : "instructions"
          },
          {
            "code" : "instructions-clinical"
          },
          {
            "code" : "instructions-admin"
          }
        ]
      }
    ]
  }
}