Da Vinci Payer Data exchange Implementation Guide Release 0.1.0

This page is part of the Da Vinci Payer Data Exchange (v0.1.0: STU 1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.1.0. For a full list of available versions, see the Directory of published versions

3-6-2 Coverage

The Coverage resource is profiled in the Da Vinci HRex IG. TODO Include link to profile.

The minimum fields to be provided in the Coverage resource are:

R4 Hierarchical Name R4 Name Card. Type    
Coverage Coverage   DomainResource    
Coverage.identifier identifier 0..* Identifier    
Coverage.status status 0..1 code    
Coverage.beneficiary beneficiary 0..1 Reference(Patient)    
Coverage.payor payor 0..* Reference(Organization Patient RelatedPerson)
Coverage.class class 0..* BackboneElement    
Coverage.class.type type 1..1 Coding    
Coverage.class.value value 1..1 string    
Coverage.costToBeneficiary.value[x] value[x] 1..1      
Coverage.costToBeneficiary.exception.type type 1..1 CodeableConcept    

3-6-2-1 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:

Line Payer Source Record Payer Source Field Data Descriptor FHIR Profile Profile Field ValueSet Notes
1.2 Member BENE_ID Patientid Coverage .beneficiary   Reference(Patient)
12.1 Member REL_CD relationship to subscriber Coverage .relationship    
13.1 Member   subscriber id Coverage .subscriberId    
1.1 Coverage   subscriber id Coverage .subscriberId    
2.1 Coverage   Coverage type Coverage .class.value https://www.hl7.org/fhir/valueset-coverage-class.html .class.type = “Type”
3.1 Coverage   Coverage status Coverage .status https://www.hl7.org/fhir/codesystem-fm-status.html  
4.1 Coverage   Start date Coverage period.start    
5.1 Coverage   End date Coverage period.end    
6.1 Coverage   Group id Coverage class.value https://www.hl7.org/fhir/valueset-coverage-class.html .class.type=”group”
7.1 Coverage   Group name Coverage class.name    
8.1 Coverage   Plan Coverage class.value https://www.hl7.org/fhir/valueset-coverage-class.html .class.type=”plan”
9.1 Coverage   Payer Coverage .payor   Reference(Organization)

Where an entry is provided in the CMS BB2.0 FIELD column the definition of the field can be reviewed using the following URL: https://bluebutton.cms.gov/resources/variables/{CMS_BB2.0_FIELD}/

Where {CMS_BB2.0_FIELD} is replaced with the Field value in lower case. For example: https://bluebutton.cms.gov/resources/variables/bene_id/

3-6-2-2 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/2"
    }
  ],
  "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"
    }
  ]
}