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FHIR IG Statistics: CodeSystem/coverage-information-codes

Packagehl7.fhir.us.davinci-crd
TypeCodeSystem
Idcoverage-information-codes
FHIR VersionR4
Sourcehttp://hl7.org/fhir/us/davinci-crd/https://build.fhir.org/ig/HL7/davinci-crd/CodeSystem-coverage-information-codes.html
URLhttp://hl7.org/fhir/us/davinci-crd/CodeSystem/coverage-information-codes
Version2.2.0-ballot
Statusactive
Date2025-07-22T17:00:27+00:00
NameCoverageInformationCodes
TitleCoverage Information Codes
Realmus
Authorityhl7
DescriptionCodes used by 'code' elements within the Coverage-Information extension.
Contentcomplete

Resources that use this resource

ValueSet
AdditionalDocumentationCRD Coverage Information Additional Documentation Value Set
DocReasonCRD Coverage Information Documentation Reason Value Set
coverageDetailCategoriesCRD Coverage Detail Categories
coverageInfoCRD Coverage Information Covered Value Set
coveragePaDetailCRD Coverage Information Prior Authorization Value Set
informationNeededCRD Information Needed Value Set

Resources that this resource uses

No resources found


Narrative

Note: links and images are rebased to the (stated) source

Generated Narrative: CodeSystem coverage-information-codes

Properties

This code system defines the following properties for its concepts

NameCodeURIType
Not Selectableabstracthttp://hl7.org/fhir/concept-properties#notSelectableboolean

Concepts

This case-sensitive code system http://hl7.org/fhir/us/davinci-crd/CodeSystem/coverage-information-codes defines the following codes in a Is-A hierarchy:

LvlCodeDisplayDefinitionNot Selectable
1conditional ConditionalThere is the potential for information requirements from a participant type not listed. However, a decision on whether there in fact are additional information requirements cannot be made without more information (more detailed code, service rendering information, etc.)
1covered CoveredRegular coverage applies
1not-covered Not coveredNo coverage or possibility of coverage for this service)
1no-auth No Prior AuthorizationThe ordered service does not require prior authorization
1auth-needed Prior Authorization NeededThe ordered service will require prior authorization
2  performpa Performer Prior AuthorizationPrior authorization is needed for the service, however such prior authoriation must be initiated by the performing (rather than ordering) provider.
1satisfied Authorization SatisfiedWhile prior authorization would typically be needed, the conditions evaluated by prior authorization have already been evaluated and therefore prior authorization can be bypassed
1clinical Clinical DocumentationDetails most likely to originate from a clinician are required to satisfy additional documentation requirements, determine coverage and/or prior auth applicability - e.g. via DTR by clinician. Indicates that the CRD client should expose the need to launch DTR to clinical users.
1admin Administrative DocumentationAdministrative details not likely to require clinical expertise are needed to satisfy additional documentation requirements, determine coverage and/or prior auth applicability - e.g. via DTR by back-end staff. Indicates that while the CRD client might expose the ability to launch DTR as an option for clinical users, it should be clear that clinical input is not necessary and deferring the use of DTR to back-end staff is perfectly appropriate. Some CRD clients might be configured (based on provider preference) to not even show clinicians the option to launch.
1patient Administrative & clinical docDetails most likely to originate from the patient or their personal representative (e.g. parent, spouse, etc.) are required to satisfy additional documentation requirements, determine coverage and/or prior auth applicability. For example, information about household composition, accessibility considerations, etc. This should be used when the data needs to come from the patient themselves, rather than a clinician's assessment of the patient
1_docReason Additional Information PurposesA collector for codes representing different reasons for capturing additional informationtrue
2  withpa Include in prior authorizationThe information in this QuestionnaireResponse should be packaged into a Bundle and submitted as part of (or in association with) a prior authorization for the associated request resource(s).
2  withclaim Include with claimThe information in this QuestionnaireResponse should be packaged into a Bundle and submitted as part of (or in association with) the insurance claim for the services ordered by the associated request resource(s).
2  withorder Include with orderThe information in this QuestionnaireResponse should be packaged into a Bundle and submitted along with (or referenced as supporting information to) the associated request resource(s) when transmitting the order to the fulfilling system.
2  retain-doc Medical necessityThe information in this QuestionnaireResponse should be retained within the EHR as supporting evidence of the medical necessity of the associated request resource(s).
1performer Performer NeededInformation about who (specifically, or at least performer type and affiliation) is necessary to make a determination of coverage and/or prior auth expectations
1location Location NeededInformation about where (specific clinic/site or organization) is necessary to make a determination of coverage and/or prior auth expectations
1timeframe Timeframe NeededInformation about when the service will be performed that is more granular than the order effective period is necessary to make a determination of coverage and/or prior auth expectations
1contract-window New Contract WindowThe target performance time for the event falls outside the contract window for the patient's current coverage. Information will not be available until a contract is in place covering the service time period
1detail-code Detail codeThe ordered code is at too high a level of granularity to make decisions about coverage/pa/etc. Can only be present if something is 'conditional'
1cat-limitation Coverage LimitationThe statement being made about coverage or authorization that are being constrained in scope in some way. I.e. It is not safe to interpret the statements of 'this is covered' or 'this does not require prior auth' without looking at this detail.
1cat-decisional Decision ConsiderationsThe statement does not qualify the coverage statement, however it does provide information that may be relevant to the patient & caregiver decision of whether a therapy is appropriate/reasonable.
1cat-other Other DetailsThe statement does not limit the coverage statement being made and is unlikely to influence a decision to proceed with care. For example, instructions on how to submit a claim, reference to to policy, etc.

Source

{
  "resourceType": "CodeSystem",
  "id": "coverage-information-codes",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode": "fm"
    },
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
      "valueInteger": 3,
      "_valueInteger": {
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical": "http://hl7.org/fhir/us/davinci-crd/ImplementationGuide/davinci-crd"
          }
        ]
      }
    },
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
      "valueCode": "trial-use",
      "_valueCode": {
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical": "http://hl7.org/fhir/us/davinci-crd/ImplementationGuide/davinci-crd"
          }
        ]
      }
    }
  ],
  "url": "http://hl7.org/fhir/us/davinci-crd/CodeSystem/coverage-information-codes",
  "identifier": [
    {
      "system": "urn:ietf:rfc:3986",
      "value": "urn:oid:2.16.840.1.113883.4.642.40.18.16.2"
    }
  ],
  "version": "2.2.0-ballot",
  "name": "CoverageInformationCodes",
  "title": "Coverage Information Codes",
  "status": "active",
  "experimental": false,
  "date": "2025-07-22T17:00:27+00:00",
  "publisher": "HL7 International / Financial Management",
  "contact": [
    {
      "telecom": [
        {
          "system": "url",
          "value": "http://www.hl7.org/Special/committees/fm"
        }
      ]
    }
  ],
  "description": "Codes used by 'code' elements within the Coverage-Information extension.",
  "jurisdiction": [
    {
      "coding": [
        {
          "system": "urn:iso:std:iso:3166",
          "code": "US"
        }
      ]
    }
  ],
  "caseSensitive": true,
  "hierarchyMeaning": "is-a",
  "content": "complete",
  "count": 23,
  "property": [
    {
      "code": "abstract",
      "uri": "http://hl7.org/fhir/concept-properties#notSelectable",
      "type": "boolean"
    }
  ],
  "concept": [
    {
      "code": "conditional",
      "display": "Conditional",
      "definition": "There is the potential for information requirements from a participant type not listed.  However, a decision on whether there in fact are additional information requirements cannot be made without more information (more detailed code, service rendering information, etc.)"
    },
    {
      "code": "covered",
      "display": "Covered",
      "definition": "Regular coverage applies"
    },
    {
      "code": "not-covered",
      "display": "Not covered",
      "definition": "No coverage or possibility of coverage for this service)"
    },
    {
      "code": "no-auth",
      "display": "No Prior Authorization",
      "definition": "The ordered service does not require prior authorization"
    },
    {
      "code": "auth-needed",
      "display": "Prior Authorization Needed",
      "definition": "The ordered service will require prior authorization",
      "concept": [
        {
          "code": "performpa",
          "display": "Performer Prior Authorization",
          "definition": "Prior authorization is needed for the service, however such prior authoriation must be initiated by the performing (rather than ordering) provider."
        }
      ]
    },
    {
      "code": "satisfied",
      "display": "Authorization Satisfied",
      "definition": "While prior authorization would typically be needed, the conditions evaluated by prior authorization have already been evaluated and therefore prior authorization can be bypassed"
    },
    {
      "code": "clinical",
      "display": "Clinical Documentation",
      "definition": "Details most likely to originate from a clinician are required to satisfy additional documentation requirements, determine coverage and/or prior auth applicability - e.g. via DTR by clinician.  Indicates that the CRD client should expose the need to launch DTR to clinical users."
    },
    {
      "code": "admin",
      "display": "Administrative Documentation",
      "definition": "Administrative details not likely to require clinical expertise are needed to satisfy additional documentation requirements, determine coverage and/or prior auth applicability - e.g. via DTR by back-end staff.  Indicates that while the CRD client might expose the ability to launch DTR as an option for clinical users, it should be clear that clinical input is not necessary and deferring the use of DTR to back-end staff is perfectly appropriate.  Some CRD clients might be configured (based on provider preference) to not even show clinicians the option to launch."
    },
    {
      "code": "patient",
      "display": "Administrative & clinical doc",
      "definition": "Details most likely to originate from the patient or their personal representative (e.g. parent, spouse, etc.) are required to satisfy additional documentation requirements, determine coverage and/or prior auth applicability.  For example, information about household composition, accessibility considerations, etc.  This should be used when the data needs to come from the patient themselves, rather than a clinician's assessment of the patient"
    },
    {
      "code": "_docReason",
      "display": "Additional Information Purposes",
      "definition": "A collector for codes representing different reasons for capturing additional information",
      "property": [
        {
          "code": "abstract",
          "valueBoolean": true
        }
      ],
      "concept": [
        {
          "code": "withpa",
          "display": "Include in prior authorization",
          "definition": "The information in this QuestionnaireResponse should be packaged into a Bundle and submitted as part of (or in association with) a prior authorization for the associated request resource(s)."
        },
        {
          "code": "withclaim",
          "display": "Include with claim",
          "definition": "The information in this QuestionnaireResponse should be packaged into a Bundle and submitted as part of (or in association with) the insurance claim for the services ordered by the associated request resource(s)."
        },
        {
          "code": "withorder",
          "display": "Include with order",
          "definition": "The information in this QuestionnaireResponse should be packaged into a Bundle and submitted along with (or referenced as supporting information to) the associated request resource(s) when transmitting the order to the fulfilling system."
        },
        {
          "code": "retain-doc",
          "display": "Medical necessity",
          "definition": "The information in this QuestionnaireResponse should be retained within the EHR as supporting evidence of the medical necessity of the associated request resource(s)."
        }
      ]
    },
    {
      "code": "performer",
      "display": "Performer Needed",
      "definition": "Information about who (specifically, or at least performer type and affiliation) is necessary to make a determination of coverage and/or prior auth expectations"
    },
    {
      "code": "location",
      "display": "Location Needed",
      "definition": "Information about where (specific clinic/site or organization) is necessary to make a determination of coverage and/or prior auth expectations"
    },
    {
      "code": "timeframe",
      "display": "Timeframe Needed",
      "definition": "Information about when the service will be performed that is more granular than the order effective period is necessary to make a determination of coverage and/or prior auth expectations"
    },
    {
      "code": "contract-window",
      "display": "New Contract Window",
      "definition": "The target performance time for the event falls outside the contract window for the patient's current coverage.  Information will not be available until a contract is in place covering the service time period"
    },
    {
      "code": "detail-code",
      "display": "Detail code",
      "definition": "The ordered code is at too high a level of granularity to make decisions about coverage/pa/etc.  Can only be present if something is 'conditional'"
    },
    {
      "code": "cat-limitation",
      "display": "Coverage Limitation",
      "definition": "The statement being made about coverage or authorization that are being constrained in scope in some way.  I.e. It is not safe to interpret the statements of 'this is covered' or 'this does not require prior auth' without looking at this detail."
    },
    {
      "code": "cat-decisional",
      "display": "Decision Considerations",
      "definition": "The statement does not qualify the coverage statement, however it does provide information that may be relevant to the patient & caregiver decision of whether a therapy is appropriate/reasonable."
    },
    {
      "code": "cat-other",
      "display": "Other Details",
      "definition": "The statement does not limit the coverage statement being made and is unlikely to influence a decision to proceed with care.  For example, instructions on how to submit a claim, reference to to policy, etc."
    }
  ]
}