| COCT_HD770005UV09 A_Benefit basic |
(Link to Excel View) Derived from RMIM: COCT_RM770005UV09 |
||||||||
| Benefit | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassCareProvision, root= "PCPR"} |
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; or may be limited by the charges covered under a P/P or financial participations required of the covered party. |
||||||||
| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodDefinition, root= "DEF"} |
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. |
||||||||
| id [0..*] Act (DSET<II>) |
Design Comments: The Benefit id: Optionally identifies a benefit. |
||||||||
| code [0..1] Act (CD) {CWE:V:x_ActBillableCode} |
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. |
||||||||
| effectiveTime [0..1] Act (IVL<TS>) |
Design Comments: The Benefit effectiveTime: The effective date range for a benefit may be sent. |
||||||||
| reasonCode [0..*] Act (DSET<CD>) {CWE:D:ActCoverageReason} |
Design Comments: The Benefit reasonCode: These are the reasons or criteria specified by codes from the ActCoverageReason value set, relating to coverage of a benefit provided under a policy or program. May be used to convey reasons pertaining to coverage contractual provisions, e.g., relating to who may provide the benefit in order to effect coverage. |
||||||||
| precondition [0..*] (Precondition) | |||||||||
| reference [0..*] (Reference) | |||||||||
| coverage [0..*] (Coverage2) | |||||||||
| Precondition | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasPre-condition, root= "PRCN"} |
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. |
||||||||
| conjunctionCode [0..1] ActRelationship (CS) {CNE:V:RelationshipConjunction} |
Design Comments: Enables multiple clinical preconditions to be considered. |
||||||||
| clinicalStatement [1..1] (A_SupportingClinicalStatementUniversal) | |||||||||
| Reference | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipRefersTo, root= "REFR"} |
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. |
||||||||
| coveragePolicy [1..1] (CoveragePolicy) | |||||||||
| CoveragePolicy | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassPolicy, root= "POLICY"} |
Design Comments: Conveys the coverage policy or policies that sets rules for the coverage of the Benefit charges and financial participations. |
||||||||
| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodDefinition, root= "DEF"} |
Design Comments: The CoveragePolicy moodCode DEF: The mood of this act is Definition, that is, coverage for a Benefit is defined by the CoveragePolicy. |
||||||||
| id [0..*] Act (DSET<II>) |
Design Comments: The CoveragePolicy id: One or more unique identifiers for the CoveragePolicy may be sent. |
||||||||
| code [0..1] Act (CD) {CWE:D:ActPolicyType} |
Design Comments: The CoveragePolicy code: The type of policy is required to be specified if known by codes from the ActPolicyType value set. |
||||||||
| statusCode [0..1] Act (CS) {CNE:V:ActStatus} |
Design Comments: The CoveragePolicy statusCode: The status of this CoveragePolicy, e.g., obsolete if this CoveragePolicy has been replaced but applied to a Benefit during the P/P effective time so as to be applicable to the coverage of a Benefit during that time span. |
||||||||
| effectiveTime [0..1] Act (IVL<TS>) |
Design Comments: The CoveragePolicy effectiveTime: The effective date range for a coverage policy may be sent. |
||||||||
| reasonCode [0..*] Act (DSET<CD>) {CWE:D:ActCoverageReason} |
Design Comments: The CoveragePolicy reasonCode: These are the reasons or criteria for the CoveragePolicy specified by codes from the ActCoverageReason value set, e.g., coverage policy for a Benefit may be related to medical necessity or evidence that a drug is not being used “off-label” or a service is not an “experimental treatment”. |
||||||||
| Coverage2 | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipCoveredBy, root= "COVBY"} |
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. |
||||||||
| coverageDefinition [1..1] (CoverageDefinition) | |||||||||
| CoverageDefinition | |||||||||
| classCode [1..1] (M) FinancialContract (CS) {CNE:V:ActClassCoverage, root= "COV"} |
Design Comments: This is the Policy or Program (P/P) master document that provides coverage for the benefit. |
||||||||
| moodCode [1..1] (M) FinancialContract (CS) {CNE:V:ActMoodDefinition, root= "DEF"} |
Design Comments: The CoverageDefinition moodCode DEF: The mood of this act is Definition, that is, this is a definition of the coverage. |
||||||||
| id [0..*] FinancialContract (DSET<II>) |
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 |
||||||||
| title [0..1] FinancialContract (ST) |
Design Comments: The CoverageDefinition title: The name by which a specific this coverage master document is generally known, e.g., Medicare Part D plan, may be sent. |
||||||||
| text [0..1] FinancialContract (ED) |
Design Comments: The CoverageDefinition text: A textual or multimedia description (or reference to a description) of the coverage master document may be sent. |
||||||||
| effectiveTime [0..1] FinancialContract (IVL<TS>) |
|||||||||