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Insurance Provider

Reference:2.2.2.5
Definition:Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.1.2.1.2 for constraints applicable to these data elements. Each unique instance of a payer or party with financial responsibility will include all the pertinent data needed to contact, bill to and collect from that party.
OID:2.16.840.1.113883.3.88.11.83.5.1
CDA Data Location HITSP Data Element Identifier and Name O/R Additional Specification
cda:act[cda:templateId/@root= '2.16.840.1.113883.10.20.1.26'] Payment Provider Event Entry See Note16 2.2.2.5.2
cda:id 5.01 -- Result ID R/N 2.2.2.5.3
cda:code/@code 5.02 - Health Insurance Type R2/N 2.2.2.5.4
cda:performer/cda:assignedEntity Payer R/N
cda:id 5.03 - Health Plan Insurance Information Source ID O/Y 2.2.2.5.5
cda:addr 5.04 - Health Plan Insurance Information Source Address O/Y 2.2.2.5.6
cda:telecom 5.05 - Health Plan Insurance Information Source Phone / Email / URL O/Y
cda:representedOrganization/cda:name 5.06 - Health Plan Insurance Information Source Name R2/N
cda:participant[@typeCode='COV'] Member information R/N 2.2.2.5.7
cda:time 5.07 - Health Plan Coverage Dates R/N 2.2.2.5.8
cda:participantRole[@classCode='PAT'] Patient
cda:id 5.08 - Member ID R2/N 2.2.2.5.9
cda:code/@code 5.09 - Patient Relationship to Subscriber R2/N 2.2.2.5.10
cda:addr 5.10 - Patient Address R2/Y 2.2.2.5.11
cda:telecom 5.11 - Patient Phone/Email/URL R2/Y
cda:playingEntity/cda:name 5.12 - Patient Name R/N 2.2.2.5.12
cda:playingEntity/sdtc:birthTime 5.13 - Patient Date of Birth R/N 2.2.2.5.13
cda:performer/cda:assignedEntity/cda:code/@code 5.14 - Financial Responsibility Party Type R2/N 2.2.2.5.14
cda:participant[@typeCode='HLD']/ cda:participantRole Subscriber Information R2/N 2.2.2.5.15
cda:id 5.15 - Subscriber ID R/N 2.2.2.5.16
cda:addr 5.16 - Subscriber Address R/N 2.2.2.5.20
cda:telecom 5.17 - Subscriber Phone/Email/URL R2/Y
cda:playingEntity/cda:name 5.18 - Subscriber Name R/N
cda:playingEntity/sdtc:birthTime 5.19 - Subscriber Date of Birth R/N 2.2.2.5.17
cda:performer[cda:assignedEntity/ cda:code[@code='' and @codeSystem=''] Guarantor Information R2/Y
cda:time 5.20 - Effective Date of Financial Responsibility R2/N
cda:assignedEntity/cda:addr 5.21 - Financial Responsibility Party Address R2/Y 2.2.2.5.18
cda:assignedEntity/cda:telecom
5.22 - Financial Responsibility Party Phone/Email/URL R2/Y
cda:assignedEntity/cda:assignedPerson/ cda:name - AND/OR -
cda:assignedEntity/ cda:representedOrganization/ cda:name 5.23 - Financial Responsibility Party Name R2/N
cda:entryRelationship[@typeCode='REFR']/ cda:act[@classCode='ACT' and @moodCode='DEF'] Health Plan R2/N 2.2.2.5.19
cda:text 5.24 - Health Plan Name R2/N

Optionality Legend: “R” for Required, “R2” for Required if known, “O” for Optional and Repeat = “Y” for Yes or “N” for No


Section ID Constraint ID Definition
2.2.2.5.1 Insurance Provider Constraints Not Provided
C83-[DE-5-CDA-1] A CDA Document SHALL declare conformance for the Insurance Provider module by including a <templateID> element with the root attribute set to the value 2.16.840.1.113883.3.88.11.83.5
C83-[DE-5-CDA-2] All Insurance Provider entries attribute set to the value 2.16.840.1.113883.3.88.11.83.5
2.2.2.5.2 Payment Provider Constraints Information for payment providers shall be recorded as a policy act inside the coverage act as described in Section 3.1 of the Continuity of Care Document Implementation Guide.
C83-[DE-5-CDA-3] Information for payment providers SHALL be recorded as a policy act inside the coverage act.

Payment Provider Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<!-- example 1 -->
<act classCode='ACT' moodCode='DEF'>
<templateId root='2.16.840.1.113883.10.20.1.20'/>
<templateId root=1.3.6.1.4.1.19376.1.5.3.1.4.17'/>
<id root=''/>
<code code='48768-6' displayName='Payment Sources' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<statusCode code='completed'/>
<!-- Example 1, A health plan -->
<entryRelationship typeCode='COMP'>
<sequenceNumber value='1'/>
<act classCode='ACT' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.26'/>
<templateId root='2.16.840.1.113883.3.88.11.83.5'/>
<id root='2844AF96-37D5-42a8-9FE3-3995C110B4F8' extension='GroupOrContract#'/>
<code code='' displayName='' codeSystem='2.16.840.1.113883.6.255.1336' codeSystemName='X12N-1336'/>
<statusCode code='completed'/>
<performer typeCode='PRF'>...</performer>
<participant typeCode='COV'>...</participant>
<participant typeCode='HLD'>...</participant>
<entryRelationship typeCode='REFR'>
<act classCode='ACT' moodCode='DEF'>...</act>
</entryRelationship>
</act>
</entryRelationship>
<!-- Example 2, A guarantor -->
<entryRelationship typeCode='COMP'>
<sequenceNumber value='2'/>
<act classCode='ACT' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.26'/>
<templateId root='2.16.840.1.113883.3.88.11.83.5'/>
<id root='2844AF96-37D5-42a8-9FE3-3995C110B4F9'/>
<code code='PP' displayName='Personal Payment' codeSystem='2.16.840.1.113883.6.255.1336' codeSystemName='X12N-1336'/>
<statusCode code='completed'/>
<performer typeCode='PRF'>
<time value='...'/>
<assignedEntity>
<id .../>
<code code='GUAR' displayName='Guarantor' codeSystem='2.16.840.1.113883.5.110' codeSystemName='RoleClass'/>
<assignedPerson><name>...</name></assignedPerson>
</assignedEntity>
</performer>
</act>
</entryRelationship>
</act>
2.2.2.5.3 Group Number Constraints The group number identifies the sponsor to the health plan with respect to the sponsored contract or policy.
C83-[DE-5.01-CDA-1] All Insurance Provider modules SHALL declare conformance to the IHE Payer Entry by including a <templateID> element with the root attribute set to the value 1.3.6.1.4.1.19376.1.5.3.1.4.18
C83-[DE-5.01-CDA-2] The root attribute SHOULD be the OID of the assigning authority for the identifier; however, determining the assigning authority is not feasible in all settings
C83-[DE-5.01-CDA-3] A GUID MAY be used in place of the OID of the assigning authority
C83-[DE-5.01-CDA-4] Implementers SHOULD use the same GUID for each instance of the same group or contract number

Group Number Constraints Example:

id root='2844AF96-37D5-42a8-9FE3-3995C110B4F8' extension='GroupOrContract#'/>
2.2.2.5.4 Healthcare Insurance Type Constraints Not Provided
C154-[DE-5.02-1] The Health Insurance Type SHALL be coded as specified in HITSP/C80 Section 2.2.2.1 Health Insurance Type

Healthcare Insurance Type Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<act classCode='ACT' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.26'/>
...
<code code='IP' displayName='Individual Policy' codeSystem='2.16.840.1.113883.6.255.1336' codeSystemName='X12N-1336'/>
...
</act>
2.2.2.5.5 Health Plan Insurance Information Source ID Constraints The information source identifier corresponds to the RxBIN and RxPCN fields found on pharmacy benefit cards. When a national payer identifier is standardized, it would also go in this field. The OID for RxBIN is 2.16.840.1.113883.3.88.3.1 The OID for an RxPCN is 2.16.840.1.113883.3.88.3.1 plus the numeric identifier used in the RxBIN

Health Plan Insurance Information Source ID Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<!-- These examples assume an RxBIN of 699999 and an RxPCN of PZZZZ -->
<performer typeCode='PRF'>
<assignedEntity classCode='ASSIGNED'>
<id root='2.16.840.1.113883.3.88.3.1' extension='699999'/>
<id root='2.16.840.1.113883.3.88.3.1.699999' extension='PZZZZ'/>
<addr>...</addr>
<telecom value='...'/>
<representedOrganization classCode='ORG'>
<name>...</name>
</representedOrganization>
</assignedEntity>
</performer>
2.2.2.5.6 Health Plan Insurance Not Provided
C154-[DE-5.04-1] The state part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.1 State
C154-[DE-5.04-3] The country part of an address SHALL be recorded using HITSP/C80 Section 2.2.1.1.3 Country
C154-[DE-5.042] The postal code part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.2 Postal Code
2.2.2.5.7 Member Information Constraints The data elements described below identify the member (patient) to the health plan for eligibility and/or claims processing. For various reasons, the health plan may not have the member's name, address or data of birth recorded in the same way as the provider has recorded the patient information. Using the member information as recorded by the health plan will improve the healthcare provider's ability to determine eligibility for benefits and reduce rejections of claims.

Member Information Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<!-- Example 1, The patient is the subscriber -->
<participant typeCode='COV'>
<time>
<low value='20070101'/>
</time>
<participantRole classCode='PAT'>
<id root='' extension=''/>
<code code='SUBSCR' displayName='subscriber' codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
<playingEntity>
<name>...</name>
<sdtc:birthTime value='...'/>
</playingEntity>
</participant>
</participant>
<!-- Example 2, The patient is a dependent of the subscriber -->
<participant typeCode='COV'>
<time>
<low value='20070209'/>
</time>
<participantRole classCode='PAT'>
<id root='' extension=''/>
<code code='DEPEND' displayName='dependent' codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
<playingEntity>
<name><given>Baby</given><family>Ross</family></name>
<sdtc:birthTime value='20070209'/>
</playingEntity>
</participant>
</participant>
2.2.2.5.8 Health Plan Coverage Dates Constraints Not Provided
C83-[DE-5.07-CDA-1] The date when the plan began covering the member SHOULD be recorded in the <low> element of the <time> element beneath the <participant>
C83-[DE-5.07-CDA-2] The date when the plan stops covering the member SHOULD be recorded in the element <high> element of the <time> element beneath the <participant>
2.2.2.5.9 Member ID Constraints Not Provided
C83-[DE-5.08-CDA-1] The member identifier number SHALL be recorded in the extension attribute of the <id> element found in the <participantRole>
C83-[DE-5.08-CDA-2] The root attribute SHOULD be the OID of the assigning authority for the identifier; however, determining the assigning authority is not feasible in all settings
C83-[DE-5.08-CDA-3] A GUID MAY be used in place of the OID of the assigning authority
C83-[DE-5.08-CDA-4] Implementers SHOULD use the same GUID for each instance of a member identifier from the same health plan
2.2.2.5.10 Relationship to Subscriber Constraints Not Provided
C154-[DE-5.09-1] The Patient Relationship to Subscriber SHALL be coded as specified in HITSP/C80 section 2.2.2.2 Subscriber Relationship
C83-[DE-5.09-CDA-1] The relationship to the subscriber SHALL be present and SHALL be recorded in the <code> element underneath the <participantRole>
2.2.2.5.11 Patient Address Constraints Not Provided
C154-[DE-5.10-1] The state part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.1 State
C154-[DE-5.10-2] The postal code part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.2 Postal Code
C154-[DE-5.10-3] The country part of an address SHALL be recorded using HITSP/C80 Section 2.2.1.1.3 Country
2.2.2.5.12 Patient Name Constraints Not Provided
C83-[DE-5.12-CDA-1] If the member name as recorded by the health plan differs from the patient name as recorded in the registration/medication summary (e.g., due to marriage or for other reasons), then the member name SHALL be recorded in the <name> element of the <playingEntity> element beneath the <participantRole>
2.2.2.5.13 Patient Date of Birth Constraints Not Provided
C83-[DE-5.13-CDA-1] If the member date of birth as recorded by the health plan differs from the patient date of birth as recorded in the registration/medication summary, then the member date of birth SHALL be recorded in the <sdtc:birthTime> element of the <playingEntity> element beneath the <participantRole>
2.2.2.5.14 Financial Responsibility Party Type Constraints This data element identifies the type of the financially responsible party.
C83-[DE-5.14-CDA-1] The code attribute SHALL be coded as specified in HITSP/C80 Section 2.2.2.3 Financially Responsible Party Type
C83-[DE-5.14-CDA-2] When the code of the encompassing act is PP, the code The attribute value SHALL be set to GUAR or PAT to represent a guarantor or self-paying patient respectively
C83-[DE-5.14-CDA-3] code attribute SHALL be set to PAYOR when the code of the encompassing act is other than PP
2.2.2.5.15 Subscriber Constraints These data elements identify the subscriber to the health plan for eligibility and/or claims processing. For various reasons, the health plan's eligibility system may not have the subscriber's name, address or data of birth recorded in the same way as the provider records it. Using the subscriber information as recorded by the eligibility system will improve the healthcare provider's ability to determine eligibility for benefits and reduce rejections of claims.
C83-[DE-5-CDA-1] When the Subscriber is the patient, the <participant> element describing the subscriber SHALL NOT be present. This information will be recorded instead in the data elements used to record member information

Subscriber Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<participant typeCode='HLD'>
<participantRole classCode='IND'>
<id root='...' extension='...'/>
<playingEntity>
<name><given>Meg</given><family>Ellen</family></name>
<sdtc:birthTime value='19600127'/>
</playingEntity>
</participant>
</participant>
2.2.2.5.16 Subscriber ID Constraints Not Provided
C83-[DE-5.15-CDA-1] The root attribute SHOULD be the OID of the assigning authority for the identifier; however, determining the assigning authority is not feasible in all settings
C83-[DE-5.15-CDA-2] A GUID MAY be used in place of the OID of the assigning authority. Implementers SHOULD use the same GUID for each instance of a subscriber identifier from the same health plan
2.2.2.5.17 Subscriber Date of Birth Constraints Not Provided
C83-[DE-5.19-CDA-1] The subscriber date of birth SHALL be recorded in the <sdtc:birthTime> element of the <playingEntity> element beneath the <participantRole> element. The <sdtc:birthTime>
2.2.2.5.18 Financial Responsibility Party Address Not Provided
C154-[DE-5.21-1] The state part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.1 State
C154-[DE-5.21-2] The postal code part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.2 Postal Code
C154-[DE-5.21-3] The country part of an address SHALL be recorded using HITSP/C80 Section 2.2.1.1.3 Country
2.2.2.5.19 Health Plan Constraints The health plan description is recorded as specified by the Policy Activity Section of the HL7 Continuity of Care Document Implementation Guide.

Health Plan Constraints Example:

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<entryRelationship typeCode='REFR'>
<act classCode='ACT' moodCode='DEF'>
<id root='2844AF96-37D5-42a8-9FE3-3995C110B4FA' extension='PlanCode'/>
<code code='HMO' displayName='health maintenance organization policy' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode'/>
<text>Health Plan Name</text>
</act>
</entryRelationship>
2.2.2.5.20 Subscriber Address Constraints Not Provided
C154-[DE-5.16-1] The state part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.1 State
C154-[DE-5.16-2] The postal code part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.2 Postal Code
C154-[DE-5.16-3] The country part of an address SHALL be recorded using HITSP/C80 Section 2.2.1.1.3 Country
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