Design Comments: The Benefit classCode PCPR: This class indicates a service provision benefit, which may be further specified by associated acts, e.g., the Benefit may have a supporting clinical statement about care provided or the condition of the subject of care as a precondition; may refer to coverage policies related to the provision of the benefit; may be limited by the charges covered under a P/P or financial participations required of the covered party; or may be defined in terms of the service specifications in the BenefitChoice.

Design Comments: The Benefit moodCode: The mood of this act is ActMoodCompletionTrack, that is, a P/P Benefit is either something that is being provided, has been provided, can be provided, or is intended or requested to be provided.

Design Comments: The Benefit code: The type of benefit is required be specified by a code from the x_ActBillableCode value set if known. For example, medical, chiropractic, dental care, social work, hospice, long term care, ambulance, acupuncture, pharmacy, psychiatry, naturopathy, physical therapy, etc.

Design Comments: The Benefit precondition ActRelationship typeCode PRCN: The Benefit may be associated to one or more A_SupportingClinicalStatement CMET, which convey the services that must be received as a precondition of coverage of the Benefit, e.g., a diagnostic test is required to validate the medical necessity of a procedure in order for that procedure to be a covered benefit under a P/P.

Design Comments: The Benefit reference ActRelationship typeCode REFR: The Benefit may reference zero or more CoverageChargePolicy, which conveys the coverage policy or policies that sets rules for the coverage of the Benefit charges and financial participations.

Design Comments: Conveys the coverage policy or policies that sets rules for the coverage of the Benefit charges and financial participations.

Design Comments: The CoveragePolicy moodCode DEF: The mood of this act is Definition, that is, coverage for a Benefit is defined by the CoveragePolicy.

Design Comments: The CoveragePolicy code: The type of policy is required to be specified if known by codes from the ActPolicyType value set.

Design Comments: The Benefit may be linked by the definition ActRelationship typeCode COVBY to zero to many CoverageDefinition. This is the Policy or Program (P/P) master document that provides coverage for the benefit.

Design Comments: This is the Policy or Program (P/P) master document that provides coverage for the benefit.

Design Comments: The CoverageDefinition moodCode DEF: The mood of this act is Definition, that is, this is a definition of the coverage.

Design Comments: The CoverageDefinition id: One or more unique identifiers for the P/P master document, which may be assigned by a jurisdictional regulator of insurance products, e.g., plan identifier, is required to be sent if available.

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

Design Comments: The Benefit may be linked by the definition ActRelationship typeCode LIMIT to zero to many PolicyOrProgramFinancialLimit. This conveys maximum amount of coverage payable under the P/P for specified periods, e.g., term of policy or life time maximum.

Design Comments: The PolicyOrProgramFinancialLimit INVE classCode: This class has an act type of Invoice.

Design Comments: The PolicyOrProgramFinancialLimit moodCode DEF: The mood of this act is Definition, that is, a PolicyOrProgramFinancialLimit rule is defined by this class's attributes.

Design Comments: The PolicyOrProgramFinancialLimit code: The P/P financial limit must be specified by a code from the ActCoverageQuantityLimitCode value set if available, e.g., limit on the amount payable under the P/P by, e.g., maximum lifetime or term of P/P contract period

Design Comments: The PolicyOrProgramLimit netAmt: Required to specify a P/P coverage limit amount, e.g., the life-time maximum for a P/P is one million dollars.

Design Comments: The Benefit limitation ActRelationship typeCode LIMIT: The Benefit may be associated with zero or more CoverageChargeChoice acts, either CoverageCharge or FinancialParticipationCharge.

Design Comments: The ActRelationship typeCode REFER: The CoverageChargeChoice may be associated to one or more CoverageChargePolicy classCode, which conveys the coverage policy or policies that sets rules for the coverage of the Benefit charges and financial participations.

Design Comments: Conveys the coverage policy or policies that sets rules for the coverage of the Benefit charges and financial participations

Design Comments: The CoverageChargePolicy moodCode DEF: The mood of this act is Definition, that is, a Benefit CoveragePolicy is defined by this class's attributes.

Design Comments: The CoverageChargePolicy code: The type of policy may be specified by codes from the ActPolicyType value set.

Design Comments: The CoverageCharge classCode INVE: This class indicates the rules relating to the charges for a benefit that a P/P will cover.

Design Comments: The CoverageCharge moodCode CRT: The mood of this act is Criterion, which conveys the conditions that must be met for the charges related to the Benefit to be covered.

Design Comments: The CoverageCharge code: The type of coverage charge rule is required to be specified if known by codes from the ActCoverageLimitCode value set, e.g., the net amount, unit quantity, or unit price.

Design Comments: The CoverageCharge may be linked by the inFullfillmentOf ActRelationship typeCode FLFS to zero to many BillingArrangementContract, a financial contract expressed with the classCode FCNTCT in definition mood DEF.

Design Comments: The FinancialParticipationCharge classCode INVE: This class indicates the rules relating to the limits of charges for a benefit that a P/P will cover.

Design Comments: The FinancialParticipationCharge moodCode CRT: The mood of this act is Criterion, which conveys the financial participation charges that the covered party must pay in order for the Benefit to be covered by the P/P.

Design Comments: The FinancialParticipationCharge code: The type of financial participation required of covered parties may be specified by codes from the ActInvoiceDetailGenericAdjudicationCode value set, e.g., copayment, deductible, or coinsurance.