| COCT_HD510002UV06 A_Coverage identified-confirmable |
(Link to Excel View) Derived from RMIM: COCT_RM510002UV06 |
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| CoverageRecord |
Design Comments: Usage Notes: The focal class of the Coverage CMET is the CoverageRecord class. This is a grouper class whose purpose is to group one or more policies or programs (P/Ps). It can group many P/Ps under different act statuses. That is, it may be used to group together those P/Ps which are: ...active (in one group) versus ...cancelled (in another group) versus ...suspended versus ...yet to become effective. The parent model should allow this CMET to repeat. A beneficiary may or may not have coverage, and the coverage may be unknown, which is conveyed by record of coverage (CoverageRecord) components of 0..* P/P, the applicability of which may be known or unknown at a particular point in time. This CMET is intended to support all of these use cases. If the CoverageRecord has no component P/Ps, this indicates that the beneficiary has a record of coverage that includes no information about P/Ps, as would be the case when the record is first created before coverage eligibility is investigated or if no eligibility is established. Thus, to indicate that a patient in the Patient PRPA_RM201301 or FIAB_RM10000 Release 2 has no coverage has no coverage, only the CoverageRecord is sent without component P/P. The CoverageRecord may consist of one or more P/Ps that have status codes indicating that they are not in effect or suspended. It may include one or more P/Ps under which the beneficiary is not covered because the type of encounter or services required are not covered by these P/Ps. Alternatively, the CoverageRecord could consist of a charity program for which a beneficiary without alternative coverages may be eligible. |
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| classCode [1..1] (M) FinancialContract (CS) {CNE:V:ActClassCoverage, root= "COV"} |
Design Comments: The CoverageRecord classCode COV: This class has an act type of Coverage. |
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| moodCode [1..1] (M) FinancialContract (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
Design Comments: The CoverageRecord moodCodeEVN: The mood of this act is Event, that is, the coverage record is something that actually happens. |
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| id [1..*] FinancialContract (DSET<II>) |
Design Comments: The CoverageRecord id: One or more unique identifiers for the CoverageRecord may be sent for use e.g., to locate the record. Note that for the A_Coverage identified and identified-confirmable variants, the lower cardinality is one and is required to be sent if available. |
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| statusCode [0..1] FinancialContract (CS) {CNE:V:ActStatus} |
Design Comments: The CoverageRecord statusCode: The status of the grouped P/Ps, that is, active, cancelled, completed (expired), suspended, etc., as discussed above. To be specified by a code from the ActStatus code. |
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| component [0..*] (Component) |
Design Comments: The CoverageRecord may be linked to one or more P/Ps, which is an instance of a policy or program included in this CoverageRecord. |
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| Component |
Design Comments: The CoverageRecord may be linked to one or more P/Ps, which is an instance of a policy or program included in this CoverageRecord. |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasComponent, root= "COMP"} |
Design Comments: The component relationship typeCode COMP: This ActRelationship links the P/P components to the CoverageRecord. COMP: A collection of sub-services as steps or subtasks performed for the source service. Services may be performed sequentially or concurrently. |
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| priorityNumber [0..1] ActRelationship (INT) |
Design Comments: The component ActRelationship priorityNumber: This attribute prioritizes coverages, that is, "1" is the primary coverage, "2" is the secondary coverage, etc. Coverage priority determines which of the P/Ps has primary responsibility for coverage and will impact coordination of benefits during the adjudication process. |
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| policyOrProgram [1..1] (PolicyOrProgram) | |||||||||
| PolicyOrProgram | |||||||||
| classCode [1..1] (M) FinancialContract (CS) {CNE:V:ActClassCoverage, root= "COV"} |
Design Comments: The PolicyOrProgram classCode COV: This class has an act type of Coverage. When used in the EVN mood, this concept means current benefits provided for a covered party by a (1) A health care insurance policy or plan that is contractually binding between two or more parties; or (2) A health care program, usually administered by government entities, that provides coverage to persons determined eligible under the terms of the program. * When used in the definition (DEF) mood, COV means potential coverage for a patient who may or may not be a covered party. * The concept's meaning is fully specified by the choice of ActCoverageTypeCode (abstract) ActProgramCode or ActInsurancePolicyCode. |
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| moodCode [1..1] (M) FinancialContract (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
Design Comments: The PolicyOrProgram moodCode EVN: The mood of this act is Event, that is, the coverage contract is something that actually happens. |
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| id [1..*] FinancialContract (DSET<II>) |
Design Comments: The PolicyOrProgram id: Zero or more unique identifiers for this policy or program must be sent if available. Note that for the A_Coverage identified and identified-confirmable variants, the lower cardinality is one. |
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| code [1..1] (M) FinancialContract (CD) {CWE:D:ActCoverageTypeCode} |
Design Comments: The PolicyOrProgram code: The coverage type of the P/P shall be specified by a code from the ActCoverageTypeCode value set, e.g., a policy for health, property and casualty, or life insurance, or a program for worker compensation, crime victim compensation, or government subsidized health program. |
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| statusCode [0..1] FinancialContract (CS) {CNE:V:ActStatus} |
Design Comments: The PolicyOrProgram statusCode: Optionally, the status of this P/P, that is, active, cancelled, completed (expired), suspended may be sent. |
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| effectiveTime [0..1] FinancialContract (IVL<TS>) |
Design Comments: The PolicyOrProgram effectiveTime: Optionally, the policy or program’s effective date and expiration date may be sent. This is the plan begin and end date range. |
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| coveredParty [1..1] (CoveredParty2) |
Design Comments: The P/P is required to be linked to one and only one CoveredParty role if known, which must be played by a kind or instance of a person, an organization, or a non-person living subject that is eligible for P/P benefits. A covered party may be a single person, an organization, or a non-person living subject. A designated population that is not individually differentiated as members of a group may play the role of covered party by being a "kind" of person or non-person living subject receiving benefits under a P/P, e.g., reproductive health education provided to all seventh grade children in a school district; needle exchange provided to all needle users within vicinity; or vaccination of a herd of cattle. Note that a kind of organization may not be a covered party. A covered party may or may not be played by the same entity who is the beneficiary, e.g., under health insurance, the beneficiary may or may not be the covered party, e.g., family counseling; under a life insurance policy the covered party is typically not the beneficiary of the policy except in the case of a viatical settlement, i.e., where the policy is sold at a discount from its face value to pay for care for a terminal illness. Covered parties may be scoped by any of the organizations playing participatory roles in the P/P as underwriters, sponsors or payors as conveyed by the E_Organization universal. The type of CoveredParty role varies by P/P type. Under a health insurance policy, the covered party is the person who is either the subscriber or dependent named in the P/P. Under a health program, the covered party is a program eligible. Under property and casualty insurance, the covered party is, for example, the claimant in a liability case or auto accident. Under life insurance, the covered party is the person in whose life the beneficiary has an insurable interest. Under reinsurance, the covered party is an underwriter. If the covered party is not known, a null flavor is sent. |
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| primaryPerformer [0..1] (PrimaryPerformer) |
Design Comments: The P/P may be linked to zero to many Payor role. The payor is the party responsible for administering the P/P, e.g., paying claims/invoices. |
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| CoveredParty2 |
Design Comments: The P/P is required to be linked to one and only one CoveredParty role if known, which must be played by a kind or instance of a person, an organization, or a non-person living subject that is eligible for P/P benefits. A covered party may be a single person, an organization, or a non-person living subject. A designated population that is not individually differentiated as members of a group may play the role of covered party by being a "kind" of person or non-person living subject receiving benefits under a P/P, e.g., reproductive health education provided to all seventh grade children in a school district; needle exchange provided to all needle users within vicinity; or vaccination of a herd of cattle. Note that a kind of organization may not be a covered party. A covered party may or may not be played by the same entity who is the beneficiary, e.g., under health insurance, the beneficiary may or may not be the covered party, e.g., family counseling; under a life insurance policy the covered party is typically not the beneficiary of the policy except in the case of a viatical settlement, i.e., where the policy is sold at a discount from its face value to pay for care for a terminal illness. Covered parties may be scoped by any of the organizations playing participatory roles in the P/P as underwriters, sponsors or payors as conveyed by the E_Organization universal. The type of CoveredParty role varies by P/P type. Under a health insurance policy, the covered party is the person who is either the subscriber or dependent named in the P/P. Under a health program, the covered party is a program eligible. Under property and casualty insurance, the covered party is, for example, the claimant in a liability case or auto accident. Under life insurance, the covered party is the person in whose life the beneficiary has an insurable interest. Under reinsurance, the covered party is an underwriter. If the covered party is not known, a null flavor is sent. |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationCoverageTarget, root= "COV"} |
Design Comments: The CoveredParty participation typeCode COV: This ActRelationship is required to associate one and only one covered party as the target of coverage under the P/P. This is not mandatory because the CoveredParty may not be known. |
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| coveredParty [1..1] (CoveredParty) |
Design Comments: The CoveredParty is played by the E_LivingSubject (informational). |
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| CoveredParty |
Design Comments: The CoveredParty is played by the E_LivingSubject (informational). |
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| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassCoveredParty, root= "COVPTY"} |
Design Comments: The CoveredParty classCode COVPTY: This shall be specified by a code from the RoleClassCoveredParty specializable value set, e.g., claimant, program eligible, named insured, individual, subscriber, or dependent. |
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| id [1..1] Role (II) |
Design Comments: The CoveredParty id: The primary identifiers for this covered party role, is assigned by the sponsor, the underwriter, or payor. These identifiers are the covered party’s identification numbers under a P/P, and may be carried on an identification card. In atypical cases, there may be more than one, e.g., covered party under a Medicaid managed care plan may be identified with both the person’s identifier as a Medicaid eligible and the identifier assigned by the contracting Medicaid managed care plan. The covered party identifier is not necessarily an OID, but may be based on the root OID of the assigning entity. |
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| code [0..1] Role (CD) {CWE:D:RoleCode} |
Design Comments: The CoveredParty code: The type of Covered Party role is required to be specified by a code from the CoverageRoleType value set, which further specifies the Covered Party Role.class, e.g., handicapped, student, military, injured worker, animal, crime victim, unemployed worker, etc. For example, a Covered Party role may have a Role.class of Named Insured and Role.code of "full time student" where the person playing the role has is covered under university health plan as a student. In addition or as an alternative, the same person may play a covered party with the Role.class of Dependent where that status is a result of also being a full time student under the age of 23. Thus, the CoveredParty Role.code of "full time student" further specifies both the Role.class of Named Insured and that of Dependent. |
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| addr [0..*] Role (COLL<AD>) |
Design Comments: The CoveredParty addr: The address of the covered party may be sent. This supports the use case where correspondence to the covered party may be different than the address of the subject playing the role, e.g., a minor who wishes to be contacted by a payer at an address different from the parent’s address. Note that the E_LivingSubject informational is proposed to be changed to include both a telecom and an addr attribute to support this use case. |
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| telecom [0..*] Role (COLL<TEL>) |
Design Comments: The CoveredParty telecom: The telecommunication numbers for the covered party may be sent. |
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| effectiveTime [0..1] Role (IVL<TS>) |
Design Comments: The CoveredParty effectiveTime: The effective date and expiration date when the covered party is covered by the P/P may be sent. If a dependent is added or deleted from the P/P, then the dependent’s effective dates will be different than the P/P effective dates. |
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| coveredEntityChoiceSubject [0..1] (E_LivingSubjectInformational) | |||||||||
| PrimaryPerformer |
Design Comments: The P/P may be linked to zero to many Payor role. The payor is the party responsible for administering the P/P, e.g., paying claims/invoices. |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationPrimaryPerformer, root= "PPRF"} |
Design Comments: The primaryPerformer participation typeCode PRPF: The type of role for this relationship is "performer". |
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| payor [1..1] (Payor) | |||||||||
| Payor | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassInvoicePayor, root= "PAYOR"} |
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| id [0..*] Role (DSET<II>) |
Design Comments: The Payor id: One or more unique identifiers for the payor is required to be sent if available. For example, an NAIC identifier |
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| name [0..*] Role (COLL<ON>) |
Design Comments: The Payor name: The name of the payor may be sent. |
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| effectiveTime [0..1] Role (IVL<TS>) |
Design Comments: The Payor effectiveTime: The effective date range for an organization in this role of payor may be sent. |
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