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Class steward is Patient Administration
The specification of the amount of financial coverage for a healthcare service or category of services. Example 1: physician office visit - 100% coverage, no co-pay in network, $15 co-pay out of network. Example 2: inpatient semi-private room rate @ 100%. Stop-loss of $2,000 per inpatient stay. Outpatient coverage: 80% with out-of-pocket limit of $2,000 per year. Note: each of the above examples would require more than one instance of this class to express.
Rationale: This class allows clinical and financial systems to communicate with payor systems regarding financial responsibility.
OpenIssue: Should this Class be 'masterized"? Is it *really* per patient, or per-plan, or associated in some other way?
A code depicting the nature of the coverage assertion (e.g. covered, excluded, coinsurance, co-pay, out-of-pocket/stop-loss, excluded, deductible, approval required, second opinion required). For example, when specifying physician office visit - 100% coverage, it indicates "coverage"; when specifying dental crowns excluded, it indicates "excluded"; when specifying psychiatric outpatient - subject to approval by Managed Care Gatekeeper, it indicates "approval required".
ExtRef: HIPAA Implementation Guide for X12 271 Transaction.
|IN1^33^00458^Lifetime Reserve Days| |IN1^34^00459^Delay Before L. R. Day| |IN1^37^00462^Policy Deductible| |IN1^39^00464^Policy Limit - Days| |IN2^19^00490^Baby Coverage| |IN2^21^00492^Blood Deductible| |IN2^24^00495^Non-Covered Insurance Code| |IN2^28^00499^Room Coverage Type/Amount| |IN2^29^00500^Policy Type/Amount| |IN2^30^00501^Daily Deductible|
The time period during which the coverage is asserted to be effective.
A indicator used to determine whether or not authorization/certification is required. For example, this would be used in specifying that psychiatric outpatient visits are subject to approval by a Managed Care Coordinator.
ExtRef: HIPAA Implementation Guide for X12 271 Transaction.
|IN3^20^00521^Pre-Certification Req/Window|
An indication as to whether the patient has reached the copay limit.
Rationale: Attribute applies to coverage class.
|IN2^67^00807^Copay Limit Flag|
A code depicting the covered parties (e.g. individual, family).
ExtRef: HIPAA Implementation Guide for X12 271 Transaction.
|IN2^19^00490^Baby Coverage| |IN2^59^00799^Policy Scope |
A code depicting the person's eligibility for coverage, e.g., for Medicaid (e.g aged, blind, disabled) or Medicare (e.g., age, disability.)
Rationale: Improves model by combining two previously distinct attributes in Medicare_coverage and Medicaid_coverage classes. There was no v2.3 x-ref for these attributes.
A code depicting the source of information about the insured's eligibility for benefits (e.g., insurance company, employer, insured presented policy, insured presented card, signed statement on file, verbal information, none, . . .).
Rationale: Attribute is related to coverage.
|IN2^27^00498^Eligibility Source|
An indicator as to whether or not the assertion applies to in-network or out-of-network. This would be used in specifying that physician office visits have a $15 co-pay for out-of-network or that physician office visits have no co-pay in-network.
ExtRef: HIPAA Implementation Guide for X12 271 Transaction.
A code indicating how the policy information was obtained.
OpenIssue: This attribute may be deleted in the future; it is similar to Healthcare_benefit_product.eligibility source code. OpenIssue: Amplify definition. Need examples, explanation.
Rationale: Attribute is related to coverage.
The amount of the coverage assertion. For example, when specifying psychiatric coverage limitation - 50 outpatient visits per year, it would have the value 50; when specifying physician office visit-$15 co-pay out-of-network, it would have the value 15. The unit of measure is specified by the quantity_qualifier_cd.
ExtRef: HIPAA Implementation Guide for X12 271 Transaction.
|IN1^33^00458^Lifetime Reserve Days| |IN1^34^00459^Delay Before L. R. Day| |IN1^37^00462^Policy Deductible| |IN1^39^00464^Policy Limit - Days| |IN2^21^00492^Blood Deductible| |IN2^28^00499^Room Coverage Type/Amount| |IN2^29^00500^Policy Type/Amount| |IN2^30^00501^Daily Deductible|
A code specifying the type of units conveyed by the qty attribute. For example, when specifying psychiatric coverage limitation - 50 outpatient visits per year, the quantity would be 50 and the quantity qualifier code would be outpatient visits; when specifying inpatient stop-loss of $2000 per inpatient stay, the quantity would be 2000 and the quantity qualifier code would be dollars.
ExtRef: HIPAA Implementation Guide for X12 271 Transaction.
|IN1^33^00458^Lifetime Reserve Days| |IN1^34^00459^Delay Before L. R. Day| |IN1^37^00462^Policy Deductible| |IN1^39^00464^Policy Limit - Days| |IN2^21^00492^Blood Deductible| |IN2^28^00499^Room Coverage Type/Amount| |IN2^29^00500^Policy Type/Amount| |IN2^30^00501^Daily Deductible|
The maximum range amount. For example, when specifying dental coverage, orthodontics covered with 50% coinsurance for ages 8-15 years, this would have the value 15.
ExtRef: HIPAA Implementation Guide for X12 271 Transaction.
The minimum range amount. For example, when specifying dental coverage, orthodontics covered with 50% coinsurance for ages 8-15 years, this would have the value 8.
ExtRef: HIPAA Implementation Guide for X12 271 Transaction.
A code depicting the unit of measure for the range low and range high quantities. For example, when specifying dental coverage, orthodontics covered with 50% coinsurance for ages 8-15 years, this would have the value years.
ExtRef: HIPAA Implementation Guide for X12 271 Transaction.
A code classifying healthcare services (e.g. physician office visit, inpatient semi-private room rate, outpatient coverage, dental, vision, orthodontics, psychiatric outpatient visit, surgical procedure).
ExtRef: HIPAA Implementation Guide for X12 271 Transaction
|IN2^21^00492^Blood Deductible| |IN2^28^00499^Room Coverage Type/Amount| |IN2^30^00501^Daily Deductible|
A code depicting a specific medical item, procedure or service (e.g. a pair of eyeglasses.)
OpenIssue: Is this attribute redundant with the connection to a masterfile class, possible Master_service? We need a better definition of the precise concept behind service_cd to know exactly to which class it belongs.
A modifier code depicting a qualifier for a particular service (e.g., bilateral procedure, repeat procedure by the same physician, distinct procedural service.)
A code depicting the time period for the benefit assertion (e.g. duration of an inpatient stay, calendar year). When specifying inpatient: stop-loss of $2,000 per inpatient stay, the value would be inpatient stay; when specifying outpatient coverage: 80% with out-of-pocket limit of $2,000 per year, the value would be year.
ExtRef: HIPAA Implementation Guide for X12 271 Transaction.
|IN2^28^00499^Room Coverage Type/Amount|
OpenIssue: Is this multiplicity correct? Is the Parent-Child tree structure correct? Is there an associative class for the relationship?
Rationale: This class now contains the attributes of a "master" class; insurance certification is associated with coverage_item.
OpenIssue: Are the multiplicities correct? Should there be an additional connection to Patient? Should there be an additional association to Healthcare_benefit_product? Or an association with a new class representing a Patient instance of a benefit product?
OpenIssue: could the coverage_item be applicable for actual services (event) too? Use case: a service was done on the basis of an emergency indication without any prior knowledge to coverage. A request is sent to a billing system or insurance, asking whether this actual service was covered and in what way it was covered?
Rationale: This class now contains the attributes of a "master" class; insurance certification is associated with coverage_item.
OpenIssue: This cardinality does not work properly since you can now link to only a single coverage item. This will only work if that linked item is the Parent. This needs to be clarified or modified in some way.
Rationale: This class now contains the attributes of a "master" class and therefore is not associated with an individual patient.
OpenIssue: Is this multiplicity correct? Is the Parent-Child tree structure correct? Is there an associative class for the relationship?