3.1 Payers

The template identifier for the Payers section is 2.16.840.1.113883.10.20.1.9.

Payers contains data on the patient’s payers, whether a ‘third party’ insurance, self-pay, other payer or guarantor, or some combination of payers, and is used to define which entity is the responsible fiduciary for the financial aspects of a patient’s care.

Each unique instance of a payer and all the pertinent data needed to contact, bill to, and collect from that payer should be included. Authorization information that can be used to define pertinent referral, authorization tracking number, procedure, therapy, intervention, device, or similar authorizations for the patient or provider, or both should be included. At a minimum, the patient’s pertinent current payment sources should be listed.

The CCD represents the sources of payment as a coverage act, which identifies all of the insurance policies or government or other programs that cover some or all of the patient's healthcare expenses. The policies or programs are sequenced by order of preference. Each policy or program identifies the covered party with respect to the payer, so that the identifiers can be recorded.

CONF-30: CCD SHOULD contain exactly one and SHALL NOT contain more than one Payers section (templateId 2.16.840.1.113883.10.20.1.9). The Payers section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more coverage activities (templateId 2.16.840.1.113883.10.20.1.20).

3.1.1 Section conformance

CONF-31: The payer section SHALL contain Section / code.
CONF-32: The value for “Section / code” SHALL be “48768-6” “Payment sources” 2.16.840.1.113883.6.1 LOINC STATIC.
CONF-33: The payer section SHALL contain Section / title.
CONF-34: Section / titleSHOULD be valued with a case-insensitive language-insensitive text string containing “insurance” or “payers”.

3.1.2 Clinical statement conformance

The following figure shows a subset of the CDA R2 model containing those classes being constrained or referred to in the conformance statements that follow.

Figure 5. CDA R2 clinical statement model for payer information

3.1.2.1 Payer representation

The template identifier for a coverage activity is 2.16.840.1.113883.10.20.1.20.
The template identifier for a policy activity is 2.16.840.1.113883.10.20.1.26.
The template identifier for an authorization activity is 2.16.840.1.113883.10.20.1.19.

Insurance and authorization acts are represented as Acts within the section. These acts are grouped together under a single coverage activity, which serves to order the payment sources. A coverage activity contains one or more policy activities, each of which contains zero or more authorization activities.

NOTE: To the extent possible, the conformance statements in this section are isomorphic and compatible with the HL7 Financial Management (FM) domain model. In some cases, CDA R2 lacks class codes or other RIM components used by FM, in which case the closest corresponding CDA R2 representation is used.

3.1.2.1.1 Coverage activity

CONF-35: A coverage activity (templateId 2.16.840.1.113883.10.20.1.20) SHALL be represented with Act.
CONF-36: The value for “Act / @classCode” in a coverage activity SHALL be “ACT” 2.16.840.1.113883.5.6 ActClass STATIC.
CONF-37: The value for “Act / @moodCode” in a coverage activity SHALL be “DEF” 2.16.840.1.113883.5.1001 ActMood STATIC.
CONF-38: A coverage activity SHALL contain at least one Act / id.
CONF-39: A coverage activity SHALL contain exactly one Act / statusCode.
CONF-40: The value for “Act / statusCode” in a coverage activity SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC.
CONF-41: A coverage activity SHALL contain exactly one Act / code.
CONF-42: The value for “Act / code” in a coverage activity SHALL be “48768-6” “Payment sources” 2.16.840.1.113883.6.1 LOINC STATIC.
CONF-43: A coverage activity SHALL contain one or more Act / entryRelationship.
CONF-44: An entryRelationship in a coverage activity MAY contain exactly one entryRelationship / sequenceNumber, which serves to prioritize the payment sources.
CONF-45: The value for “Act / entryRelationship / @typeCode” in a coverage activity SHALL be “COMP” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC.
CONF-46: The target of a coverage activity SHALL be a policy activity (templateId 2.16.840.1.113883.10.20.1.26).
CONF-47: A coverage activity SHALL contain one or more sources of information, as defined in section 5.2 Source.

3.1.2.1.2 Policy Activity

A policy activity represents the policy or program providing the coverage. The person for whom payment is being provided (i.e. the patient) is the covered party. The subscriber of the policy or program is represented as a participant that is the holder the coverage. The payer is represented as the performer of the policy activity.

CONF-48: A policy activity (templateId 2.16.840.1.113883.10.20.1.26) SHALL be represented with Act.
CONF-49: The value for “Act / @classCode” in a policy activity SHALL be “ACT” 2.16.840.1.113883.5.6 ActClass STATIC.
CONF-50: The value for “Act / @moodCode” in a policy activity SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC.
CONF-51: A policy activity SHALL contain at least one Act / id, which represents the group or contract number related to the insurance policy or program.
CONF-52: A policy activity SHALL contain exactly one Act / statusCode.
CONF-53: The value for “Act / statusCode” in a policy activity SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC.
CONF-54: A policy activity SHOULD contain zero to one Act / code., which represents the type of coverage.
CONF-55: The value for “Act / code” in a policy activity SHOULD be selected from ValueSet 2.16.840.1.113883.1.11.19832 ActCoverageType DYNAMIC.
CONF-56: A policy activity SHALL contain exactly one Act / performer [@typeCode=”PRF”], representing the payer.
CONF-57: A payer in a policy activity SHALL contain one or more performer / assignedEntity / id, to represent the payer identification number. For pharamacy benefit programs this can be valued using the RxBIN and RxPCN numbers assigned by ANSI and NCPDP respectively. When a nationally recognized payer identification number is available, it would be placed here.
CONF-58: A policy activity SHALL contain exactly one Act / participant [@typeCode=”COV”], representing the covered party.
CONF-59: A covered party in a policy activity SHOULD contain one or more participant / participantRole / id, to represent the patient’s member or subscriber identifier with respect to the payer.
CONF-60: A covered party in a policy activity SHOULD contain exactly one participant / participantRole / code, to represent the reason for coverage (e.g. Self, Family dependent, student).
CONF-61: The value for “participant / participantRole / code” in a policy activity’s covered party MAY be selected from ValueSet 2.16.840.1.113883.1.11.19809 PolicyOrProgramCoverageRoleType DYNAMIC.
CONF-62: A covered party in a policy activity MAY contain exactly one participant / time, to represent the time period over which the patient is covered.
CONF-63: A policy activity MAY contain exactly one Act / participant [@typeCode=”HLD”], representing the subscriber.
CONF-64: A subscriber in a policy activity SHOULD contain one or more participant / participantRole / id, to represent the subscriber’s identifier with respect to the payer.
CONF-65: A subscriber in a policy activity MAY contain exactly one participant / time, to represent the time period for which the subscriber is enrolled.
CONF-66: The value for “Act / entryRelationship / @typeCode” in a policy activity SHALL be “REFR” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC.
CONF-67: The target of a policy activity with Act / entryRelationship / @typeCode=”REFR” SHALL be an authorization activity (templateId 2.16.840.1.113883.10.20.1.19) or an Act, with Act [@classCode = “ACT”] and Act [@moodCode = “DEF”], representing a description of the coverage plan. CONF-68: A description of the coverage plan SHALL contain one or more Act / Id, to represent the plan identifier.

3.1.2.1.3 Authorization Activity

An authorization activity represents authorizations or pre-authorizations currently active for the patient for the particular payer.

Authorizations are represented using an act subordinate to the policy or program that provided it. The policy or program is referred to by the authorization. Authorized treatments can be grouped into an Organizer class, where common properties, such as the reason for the authorization, can be expressed. Subordinate acts represent what was authorized.

CONF-69: An authorization activity (templateId 2.16.840.1.113883.10.20.1.19) SHALL be represented with Act.
CONF-70: The value for “Act / @classCode” in an authorization activity SHALL be “ACT” 2.16.840.1.113883.5.6 ActClass STATIC.
CONF-71: An authorization activity SHALL contain at least one Act / id.
CONF-72: The value for “Act / @moodCode” in an authorization activity SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC.
CONF-73: An authorization activity SHALL contain one or more Act / entryRelationship.
CONF-74: The value for “Act / entryRelationship / @typeCode” in an authorization activity SHALL be “SUBJ” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC.
CONF-75: The target of an authorization activity with Act / entryRelationship / @typeCode=”SUBJ” SHALL be a clinical statement with moodCode = “PRMS” (Promise).
CONF-76: The target of an authorization activity MAY contain one or more performer, to indicate the providers that have been authorized to provide treatment.