Non-Normative Content The Normative content for these specifications may be found on the HL7, IHE, and HITSP web sites.

Policy Activity

[Act: templateId 2.16.840.1.113883.10.20.22.4.61]

A policy activity represents the policy or program providing the coverage.

  1. SHALL contain exactly one [1..1] templateId ( CONF:8900, CONF:10516 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.61"
  2. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:8898)
  3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: 2.16.840.1.113883.5.1001 HL7ActMood) (CONF:8899)
  4. SHALL contain exactly one [1..1] code (CONF:8903), where the @code SHOULD be selected from ValueSet Health Insurance Type Value Set 2.16.840.1.113883.3.88.12.3221.5.2 STATIC 20081218 (CONF:15993)
  5. SHALL contain at least one [1..*] id (CONF:8901, CONF:10119)
    • This id is a unique identifier for the policy or program providing the coverage

  6. SHALL contain exactly one [1..1] statusCode/@code="completed" Completed (CodeSystem: 2.16.840.1.113883.5.14 ActStatus) (CONF:8902)
  7. SHALL contain exactly one [1..1] performer (CONF:8906)
    1. This performer SHALL contain exactly one [1..1] @typeCode="PRF" (CONF:8907)
    2. This performer SHALL contain exactly one [1..1] assignedEntity (CONF:8908)
      1. This assignedEntity SHALL contain at least one [1..*] id (CONF:8909)
      2. This assignedEntity SHALL contain exactly one [1..1] code (CONF:8914), where the @code SHALL be selected from ValueSet Financially Responsible Party Type Value Set 2.16.840.1.113883.1.11.10416 STATIC 1 (CONF:15992)
      3. This assignedEntity MAY contain zero or one [0..1] addr with data type US Realm Address (CONF:8910, CONF:10481)
      4. This assignedEntity MAY contain zero or one [0..1] telecom (CONF:8910)
      5. This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:8912)
        1. This representedOrganization SHOULD contain zero or one [0..1] name (CONF:8913)
      6. This assignedEntity The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10481)
  8. SHOULD contain zero or one [0..1] performer (CONF:8961)
    1. This performer SHOULD contain exactly one [1..1] @typeCode="PRF" (CONF:8961)
    2. This performer SHOULD contain exactly one [1..1] time (CONF:8963)
    3. This performer SHALL contain exactly one [1..1] assignedEntity (CONF:8962)
      1. This assignedEntity SHALL contain exactly one [1..1] code (CONF:8968)/@code="GUAR" Guarantor (CodeSystem: 2.16.840.1.113883.5.110 HL7RoleClass) (CONF:16096)
      2. This assignedEntity SHOULD contain zero or one [0..1] addr with data type US Realm Address (CONF:8964, CONF:10482)

        The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10482)

      3. This assignedEntity SHOULD contain zero or one [0..1] telecom (CONF:8965)
      4. This assignedEntity SHOULD include assignedEntity/assignedPerson/name AND/OR assignedEntity/representedOrganization/name (CONF:8967)
      5. This assignedEntity The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2) (CONF:10482)
  9. SHALL contain exactly one [1..1] participant (CONF:8916)
    1. This participant SHALL contain exactly one [1..1] @typeCode="COV" (CONF:8917)
    2. This participant SHOULD contain zero or one [0..1] time (CONF:8918)
    3. This participant SHALL contain exactly one [1..1] participantRole (CONF:8921)
      1. This participantRole SHALL contain at least one [1..*] id (CONF:8922)
      2. This participantRole SHALL contain exactly one [1..1] code (CONF:8923), where the @code SHALL be selected from ValueSet Coverage Role Type Value Set 2.16.840.1.113883.1.11.18877 DYNAMIC (CONF:16078, CONF:8924)
      3. This participantRole SHOULD contain zero or one [0..1] addr with data type US Realm Address (CONF:8956)
      4. This participantRole SHOULD contain zero or one [0..1] playingEntity (CONF:8932)
        1. This playingEntity SHALL contain exactly one [1..1] name (CONF:8930)

          a. 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 (CONF:8931)

        2. This playingEntity 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 sdtc:birthTime. (CONF:8933)
    4. This participant The time, if present, SHOULD contain zero or one [0..1] low (CONF:8919)
    5. This participant The time, if present, SHOULD contain zero or one [0..1] high (CONF:8920)
  10. SHOULD contain zero or one [0..1] participant (CONF:8934)
    1. This participant SHALL contain exactly one [1..1] @typeCode="HLD" (CONF:8935)
    2. This participant MAY contain zero or one [0..1] time (CONF:8938)
    3. This participant SHALL contain exactly one [1..1] participantRole (CONF:8936)
      1. This participantRole SHALL contain at least one [1..*] id (CONF:8937)

        This id is a unique identifier for the subscriber of the coverage (CONF:10120)

      2. This participantRole SHOULD contain zero or one [0..1] addr with data type US Realm Address (CONF:8925)
  11. SHALL contain at least one [1..*] entryRelationship (CONF:8939)
    1. Such entryRelationships SHALL contain exactly one [1..1] @typeCode="REFR" (CONF:8940)
    2. Such entryRelationships 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:8942)
    3. Such entryRelationships A description of the coverage plan SHALL contain one or more act/id, to represent the plan identifier, and an act/text with the name of the plan (CONF:8943)

Policy Activity example

<act xmlns="urn:hl7-org:v3">
  <id root="MDHT" extension="1618286417"/>
  <code code="347633970"/>
  <effectiveTime>
    <low value="2013"/>
    <high value="2013"/>
  </effectiveTime>
  <performer typeCode="PRF">
    <templateId root="2.16.840.1.113883.10.20.22.4.87"/>
    <assignedEntity>
      <id root="MDHT" extension="491141097"/>
      <code codeSystem="2.16.840.1.113883.5.110" codeSystemName="HL7RoleClass"/>
      <telecom/>
      <representedOrganization/>
    </assignedEntity>
  </performer>
  <performer typeCode="PRF">
    <templateId root="2.16.840.1.113883.10.20.22.4.88"/>
    <time>
      <low value="2013"/>
      <high value="2013"/>
    </time>
    <assignedEntity>
      <id root="MDHT" extension="503244342"/>
      <code code="GUAR" codeSystem="2.16.840.1.113883.5.110" codeSystemName="HL7RoleClass" displayName="Guarantor"/>
      <telecom/>
    </assignedEntity>
  </performer>
  <participant typeCode="COV">
    <templateId root="2.16.840.1.113883.10.20.22.4.89"/>
    <time>
      <low value="2013"/>
      <high value="2013"/>
    </time>
    <participantRole>
      <id root="MDHT" extension="1460958578"/>
      <code codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode"/>
      <playingEntity/>
    </participantRole>
  </participant>
  <participant typeCode="HLD">
    <templateId root="2.16.840.1.113883.10.20.22.4.90"/>
    <time>
      <low value="2013"/>
      <high value="2013"/>
    </time>
    <participantRole>
      <id root="MDHT" extension="1794751557"/>
    </participantRole>
  </participant>
  <entryRelationship typeCode="REFR"/>
</act>