| COCT_HD510005UV06 A_Coverage basic |
(Link to Excel View) Derived from RMIM: COCT_RM510005UV06 |
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| CoverageRecord | |||||||||
| classCode [1..1] (M) FinancialContract (CS) {CNE:V:ActClassCoverage, root= "COV"} |
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| moodCode [1..1] (M) FinancialContract (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| id [0..*] FinancialContract (DSET<II>) |
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| statusCode [0..1] FinancialContract (CS) {CNE:V:ActStatus} |
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| effectiveTime [0..1] FinancialContract (IVL<TS>) |
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| component [0..*] (Component) | |||||||||
| Component | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasComponent, root= "COMP"} |
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| priorityNumber [0..1] ActRelationship (INT) |
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| policyOrProgram [1..1] (PolicyOrProgram) | |||||||||
| PolicyOrProgram | |||||||||
| classCode [1..1] (M) FinancialContract (CS) {CNE:V:ActClassCoverage, root= "COV"} |
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| moodCode [1..1] (M) FinancialContract (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| id [0..*] FinancialContract (DSET<II>) |
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| code [1..1] (M) FinancialContract (CD) {CWE:D:ActCoverageTypeCode} |
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| statusCode [0..1] FinancialContract (CS) {CNE:V:ActStatus} |
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| effectiveTime [0..1] FinancialContract (IVL<TS>) |
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| coveredParty [1..1] (CoveredParty2) | |||||||||
| holder [0..1] (Holder) | |||||||||
| responsibleParty [0..1] (ResponsibleParty1) | |||||||||
| primaryPerformer [0..*] (PrimaryPerformer) | |||||||||
| definition [0..1] (Definition2) | |||||||||
| replacementOf [0..1] (ReplacementOf) | |||||||||
| coverage [0..*] (Coverage2) | |||||||||
| limitation [0..*] (Limitation3) | |||||||||
| CoveredParty2 | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationCoverageTarget, root= "COV"} |
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| negationInd [0..1] Participation (BL){default= "true"} |
Design Comments: If the optional negationInd is sent, the value should be "true". The receiving application will interpret this as meaning that the coverage participation is negated. If the optional negationInd is not sent, then the receiving application assumes the negationInd value is "false" meaning that the participation is correct. |
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| coveredParty [1..1] (CoveredParty) | |||||||||
| CoveredParty | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassCoveredParty, root= "COVPTY"} |
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| id [1..1] Role (II) |
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| code [0..1] Role (CD) {CNE:V:CoverageRoleType} |
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| addr [0..*] Role (COLL<AD>) |
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| telecom [0..*] Role (COLL<TEL>) |
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| effectiveTime [0..1] Role (IVL<TS>) |
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| coveredPartyChoice [0..1] (CoveredPartyChoice) | |||||||||
| underwritingOrganization [0..1] (E_OrganizationUniversal) | |||||||||
| subjectOf [0..*] (Subject2) | |||||||||
| indirectAuthority1 [0..*] (IndirectAuthorithyOver) | |||||||||
| indirectAuthority2 [0..1] (IndirectAuthorithyOver2) | |||||||||
| CoveredPartyChoice | |||||||||
| choice of E_OrganizationUniversal | |||||||||
| or E_LivingSubjectInformational | |||||||||
| Subject2 | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationTargetSubject, root= "SBJ"} |
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| verification [1..1] (A_VerificationUniversal) | |||||||||
| IndirectAuthorithyOver | |||||||||
| typeCode [1..1] (M) RoleLink (CS) {CNE:V:RoleLinkHasIndirectAuthorityOver, root= "INDAUTH"} |
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| responsibleParty [1..1] (ResponsibleParty) | |||||||||
| ResponsibleParty | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassAgent, root= "AGNT"} |
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| id [0..*] Role (DSET<II>) |
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| code [0..1] Role (CD) {CWE:D:ResponsiblePartyRoleType} |
UsageNotes: ERROR - Business name from Visio is too long and was truncated. Full businessName follows. (Party responsible for the status of an entity as a covered party dependent, e.g., subscriber, guardian, executor |
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| addr [0..*] Role (COLL<AD>) |
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| telecom [0..*] Role (COLL<TEL>) |
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| agentPerson [0..1] (Person) | |||||||||
| representedEntityChoice [0..1] (EntityChoice) | |||||||||
| Person | |||||||||
| classCode [1..1] (M) Person (CS) {CNE:V:EntityClassPerson, root= "PSN"} |
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| determinerCode [1..1] (M) Person (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
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| name [1..*] Person (COLL<PN>) |
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| telecom [0..*] Person (COLL<TEL>) |
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| birthTime [0..1] Person (TS) |
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| addr [0..*] Person (COLL<AD>) |
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| EntityChoice | |||||||||
| choice of Person | |||||||||
| or Organization | |||||||||
| Organization | |||||||||
| classCode [1..1] (M) Organization (CS) {CNE:V:EntityClassOrganization, root= "ORG"} |
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| determinerCode [1..1] (M) Organization (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
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| name [1..*] Organization (COLL<ON>) |
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| telecom [0..*] Organization (COLL<TEL>) |
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| addr [0..1] Organization (AD) |
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| IndirectAuthorithyOver2 | |||||||||
| typeCode [1..1] (M) RoleLink (CS) {CNE:V:RoleLinkHasIndirectAuthorityOver, root= "INDAUTH"} |
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| policyHolder [1..1] (PolicyHolder) | |||||||||
| PolicyHolder | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassPolicyHolder, root= "POLHOLD"} |
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| id [0..1] Role (II) |
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| addr [0..*] Role (COLL<AD>) |
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| telecom [0..*] Role (COLL<TEL>) |
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| policyHolderEntityChoice [0..1] (EntityChoice) | |||||||||
| underwritingOrganization [0..1] (E_OrganizationUniversal) | |||||||||
| Holder | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationHolder, root= "HLD"} |
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| policyHolder [1..1] (PolicyHolder) | |||||||||
| ResponsibleParty1 | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationResponsibleParty, root= "RESP"} |
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| sponsor [1..1] (Sponsor) | |||||||||
| Sponsor | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassCoverageSponsor, root= "SPNSR"} |
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| id [0..*] Role (DSET<II>) |
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| code [0..1] Role (CD) {CWE:D:RoleCode} |
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| name [0..*] Role (COLL<ON>) |
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| addr [0..*] Role (COLL<AD>) |
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| telecom [0..*] Role (COLL<TEL>) |
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| effectiveTime [0..1] Role (IVL<TS>) |
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| sponsorOrganization [0..1] (E_OrganizationUniversal) | |||||||||
| PrimaryPerformer | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationPrimaryPerformer, root= "PPRF"} |
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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>) |
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| code [0..1] Role (CD) {CWE:D:RoleCode} |
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| name [0..*] Role (COLL<ON>) |
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| addr [0..*] Role (COLL<AD>) |
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| telecom [0..*] Role (COLL<TEL>) |
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| effectiveTime [0..1] Role (IVL<TS>) |
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| invoicePayorOrganization [0..1] (E_OrganizationUniversal) | |||||||||
| Definition2 | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipInstantiatesMaster, root= "INST"} |
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| coverageDefinition [1..1] (CoverageDefinition) | |||||||||
| CoverageDefinition | |||||||||
| classCode [1..1] (M) FinancialContract (CS) {CNE:V:ActClassCoverage, root= "COV"} |
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| moodCode [1..1] (M) FinancialContract (CS) {CNE:V:ActMoodDefinition, root= "DEF"} |
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| id [0..*] FinancialContract (DSET<II>) |
UsageNotes: ERROR - Business name from Visio is too long and was truncated. Full businessName follows. (identifier assigned to the policy or program master document by a jurisdictional regulator of insurance products, e.g., plan identifer |
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| ReplacementOf | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipReplaces, root= "RPLC"} |
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| previousPolicyOrProgram [1..1] (PreviousPolicyOrProgram) | |||||||||
| PreviousPolicyOrProgram | |||||||||
| classCode [1..1] (M) FinancialContract (CS) {CNE:V:ActClassCoverage, root= "COV"} |
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| moodCode [1..1] (M) FinancialContract (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| id [0..*] FinancialContract (DSET<II>) |
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| statusCode [1..1] FinancialContract (CS) {CNE:D:_NotDefined} |
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| effectiveTime [0..1] FinancialContract (IVL<TS>) |
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| Coverage2 | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipCoveredBy, root= "COVBY"} |
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| negationInd [0..1] ActRelationship (BL) |
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| benefit [1..1] (Benefit) | |||||||||
| Benefit | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassCareProvision, root= "PCPR"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodCompletionTrack} |
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| code [0..1] Act (CD) {CWE:V:x_ActBillableCode} |
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| negationInd [0..1] Act (BL) |
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| effectiveTime [0..1] Act (IVL<TS>) |
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| reasonCode [0..*] Act (DSET<CD>) {CWE:D:ActCoverageReason} |
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| definition [0..*] (Definition) | |||||||||
| limitation [0..*] (Limitation) | |||||||||
| Definition | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipInstantiatesMaster, root= "INST"} |
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| benefitChoice [1..1] (BenefitChoice) |
Design Comments: The A_SupportingClinicalStatement and A_TransportationCMETs will be replaced with the A_CareStatement CMET RM00100 in DEF ActMood |
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| BenefitChoice |
Design Comments: The A_SupportingClinicalStatement and A_TransportationCMETs will be replaced with the A_CareStatement CMET RM00100 in DEF ActMood |
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| choice of ServiceDefinition | |||||||||
| or A_BillableUniversal | |||||||||
| or A_SupportingClinicalStatementUniversal | |||||||||
| or A_TransportationUniversal | |||||||||
| ServiceDefinition | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassRoot, root= "ACT"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodDefinition, root= "DEF"} |
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| code [0..1] Act (CD) {CWE:D:ActBillableCode} |
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| Limitation | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipLimitedBy, root= "LIMIT"} |
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| coverageChargeChoice [1..1] (CoverageChargeChoice) | |||||||||
| CoverageChargeChoice | |||||||||
| choice of CoverageCharge | |||||||||
| or FinancialParticipationCharge | |||||||||
| CoverageCharge | |||||||||
| classCode [1..1] (M) InvoiceElement (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"} |
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| moodCode [1..1] (M) InvoiceElement (CS) {CNE:V:ActMoodCriterion, root= "CRT"} |
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| id [0..*] InvoiceElement (DSET<II>) |
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| code [0..1] InvoiceElement (CD) {CWE:D:ActCoverageLimitCode} |
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| effectiveTime [0..1] InvoiceElement (IVL<TS>) |
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| unitQuantity [0..1] InvoiceElement (RTO<PQ,PQ>) |
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| unitPriceAmt [0..1] InvoiceElement (RTO<MO,PQ>) |
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| netAmt [0..1] InvoiceElement (MO) |
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| factorNumber [0..1] InvoiceElement (REAL) |
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| FinancialParticipationCharge | |||||||||
| classCode [1..1] (M) InvoiceElement (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"} |
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| moodCode [1..1] (M) InvoiceElement (CS) {CNE:V:ActMoodCriterion, root= "CRT"} |
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| code [0..1] InvoiceElement (CD) {CWE:V:ActInvoiceDetailGenericAdjudicatorCode} |
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| effectiveTime [0..1] InvoiceElement (IVL<TS>) |
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| unitQuantity [0..1] InvoiceElement (RTO<PQ,PQ>) |
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| unitPriceAmt [0..1] InvoiceElement (RTO<MO,PQ>) |
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| netAmt [0..1] InvoiceElement (MO) |
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| Limitation3 | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipLimitedBy, root= "LIMIT"} |
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| coverageLimitObservation [1..1] (CoverageLimitObservation) | |||||||||
| CoverageLimitObservation | |||||||||
| classCode [1..1] (M) Observation (CS) {CNE:V:ActClassObservation, root= "OBS"} |
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| moodCode [1..1] (M) Observation (CS) {CNE:V:ActMoodDefinition, root= "DEF"} |
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| id [0..*] Observation (DSET<II>) |
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| code [0..1] Observation (CD) {CWE:D:ActCoverageLimitObservationCode} |
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| effectiveTime [0..1] Observation (IVL<TS>) |
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| value [0..1] Observation (CD) {CWE:D:CoverageLimitObservationValue} |
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