description: 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 of the coverage. The payer is represented as the performer of the policy activity.\nNote that the absence of a Policy Activity Act is not confirmation the patient does not have coverage. A Patient's coverage may not have been documented yet or not known to the healthcare provider. \n*    Absence of a Policy Activity Act may mean that the patient has no coverage or the healthcare provider may not know it.\n*    A self pay payer type MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs.
package_name: hl7.cda.us.ccda
derivation: constraint
name: PolicyActivity
type: http://hl7.org/cda/stds/core/StructureDefinition/Act
elements:
  entryRelationship:
    index: 65
    slicing:
      rules: open
      discriminator:
      - {path: act.moodCode, type: value}
      min: null
      slices:
        authorization:
          match:
            act: {moodCode: null}
          schema:
            short: entryRelationship
            array: true
            index: 66
            elements:
              typeCode:
                pattern: {type: Code, value: REFR}
                index: 67
              act:
                type: http://hl7.org/cda/stds/core/StructureDefinition/Act
                index: 68
                elements:
                  moodCode: {short: EVN, index: 69}
            required: [act]
        plan:
          match:
            act: {moodCode: DEF}
          schema:
            short: Represents the Coverage Plan
            array: true
            index: 70
            elements:
              typeCode:
                pattern: {type: Code, value: REFR}
                index: 71
              act:
                index: 72
                elements:
                  classCode:
                    pattern: {type: Code, value: ACT}
                    index: 73
                  moodCode:
                    pattern: {type: Code, value: DEF}
                    index: 74
                  id: {short: Plan identifier, index: 75}
                  text: {short: Name of the plan, index: 76}
                required: [id, text]
            required: [act]
  participant:
    index: 39
    slicing:
      rules: open
      discriminator:
      - {path: typeCode, type: value}
      min: 1
      slices:
        coverage-target:
          match: {typeCode: COV}
          schema:
            short: participant
            constraint:
              should-time: {human: SHOULD contain time, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity', severity: warning, expression: time.exists()}
            _required: true
            index: 40
            elements:
              templateId:
                index: 41
                elements:
                  root:
                    pattern: {type: String, value: 2.16.840.1.113883.10.20.22.4.89}
                    index: 42
                  extension: {index: 43}
                required: [root]
                extensions: {}
              typeCode:
                pattern: {type: Code, value: COV}
                index: 44
              time:
                short: This records the policy coverage period or self-pay period.
                constraint:
                  should-low: {human: SHOULD contain low, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity', severity: warning, expression: low.exists()}
                  should-high: {human: SHOULD contain high, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity', severity: warning, expression: high.exists()}
                index: 45
                elements:
                  low: {index: 46}
                  high: {index: 47}
              participantRole:
                constraint:
                  should-addr: {human: SHOULD contain addr, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity', severity: warning, expression: addr.exists()}
                  should-playingEntity: {human: SHOULD contain playingEntity, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity', severity: warning, expression: playingEntity.exists()}
                index: 48
                elements:
                  id: {short: '𝗨𝗦𝗖𝗗𝗜: **MEMBER IDENTIFIER**: This id is a unique identifier for  the covered party member. Implementers **SHOULD** use the same GUID for each instance of a member identifier from the same health plan (CONF:4537-8984).', index: 49}
                  code:
                    short: '𝗨𝗦𝗖𝗗𝗜: **RELATIONSHIP TO SUBSCRIBER**: Records the relationship of a patient to the primary insured person.'
                    constraint:
                      should-code-attr: {human: SHOULD contain @code, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity', severity: warning, expression: code.exists()}
                    index: 50
                    elements:
                      code:
                        binding: {strength: preferred, valueSet: 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.18877'}
                        index: 51
                  addr: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/AD', index: 52}
                  playingEntity:
                    short: This playingEntity records the covered party name and birthTime as represented by the health plan. This could match the information in recordTarget, or be different due to marriage or other reasons.
                    index: 53
                    elements:
                      name: {index: 54}
                      sdtcBirthTime: {short: 'sdtc:birthTime', index: 55}
                    required: [sdtcBirthTime, name]
                required: [id, code]
            required: [templateId]
        subscriber:
          match: {typeCode: HLD}
          schema:
            short: 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.
            index: 56
            elements:
              templateId:
                index: 57
                elements:
                  root:
                    pattern: {type: String, value: 2.16.840.1.113883.10.20.22.4.90}
                    index: 58
                  extension: {index: 59}
                required: [root]
                extensions: {}
              typeCode:
                pattern: {type: Code, value: HLD}
                index: 60
              time: {index: 61}
              participantRole:
                constraint:
                  should-addr: {human: SHOULD contain addr, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity', severity: warning, expression: addr.exists()}
                index: 62
                elements:
                  id: {short: '𝗨𝗦𝗖𝗗𝗜: **SUBSCRIBER ID**: This id is a unique identifier for the subscriber of the coverage (CONF:4537-10120).', index: 63}
                  addr: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/AD', index: 64}
                required: [id]
            required: [templateId]
  classCode:
    pattern: {type: Code, value: ACT}
    index: 4
  id: {short: '𝗨𝗦𝗖𝗗𝗜: **GROUP NUMBER**: This is the identifier used to uniquely refer to a specific health insurance plan.', index: 6}
  code:
    elements:
      code:
        binding: {strength: preferred, valueSet: 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591'}
        index: 7
  moodCode:
    pattern: {type: Code, value: EVN}
    index: 5
  templateId:
    index: 0
    slicing:
      rules: open
      discriminator:
      - {path: root, type: value}
      - {path: extension, type: value}
      min: 1
      slices:
        policy-activity:
          match: {root: 2.16.840.1.113883.10.20.22.4.61, extension: '2024-05-01'}
          schema:
            _required: true
            index: 1
            elements:
              root:
                pattern: {type: String, value: 2.16.840.1.113883.10.20.22.4.61}
                index: 2
              extension:
                pattern: {type: String, value: '2024-05-01'}
                index: 3
            required: [root, extension]
            extensions: {}
  statusCode:
    index: 10
    elements:
      code:
        pattern: {type: Code, value: completed}
        index: 11
    required: [code]
  performer:
    index: 12
    slicing:
      rules: open
      discriminator:
      - {path: templateId.root, type: value}
      min: 1
      slices:
        payer:
          match:
            templateId: {root: 2.16.840.1.113883.10.20.22.4.87}
          schema:
            short: This performer represents the Payer.
            _required: true
            index: 13
            elements:
              templateId:
                index: 14
                elements:
                  root:
                    pattern: {type: String, value: 2.16.840.1.113883.10.20.22.4.87}
                    index: 15
                  extension: {index: 16}
                required: [root]
                extensions: {}
              typeCode: {index: 17}
              assignedEntity:
                constraint:
                  should-code: {human: SHOULD contain code, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity', severity: warning, expression: code.exists()}
                  should-representedOrganization: {human: SHOULD contain representedOrganization, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity', severity: warning, expression: representedOrganization.exists()}
                index: 18
                elements:
                  id: {short: '𝗨𝗦𝗖𝗗𝗜: **PAYER IDENTIFIER**: This is the Payer id. The root is a unique identifier to an openly available assigning authority, such as National Association of Insurance Commissioners (NAIC) (2.16.840.1.113883.6.300), and the extension identifiers the payer within that authority.', index: 19}
                  code:
                    index: 20
                    elements:
                      nullFlavor: {index: 21}
                      code:
                        binding: {strength: preferred, valueSet: 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.10416'}
                        index: 22
                    required: [code]
                  addr: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/AD', index: 23}
                  telecom: {index: 24}
                  representedOrganization:
                    constraint:
                      should-name: {human: SHOULD contain name, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity', severity: warning, expression: name.exists()}
                    index: 25
                    elements:
                      name: {index: 26}
            required: [typeCode, templateId]
        guarantor:
          match:
            templateId: {root: 2.16.840.1.113883.10.20.22.4.88}
          schema:
            short: This performer represents the Guarantor.
            constraint:
              should-time: {human: SHOULD contain time, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity', severity: warning, expression: time.exists()}
            array: true
            index: 27
            elements:
              templateId:
                index: 28
                elements:
                  root:
                    pattern: {type: String, value: 2.16.840.1.113883.10.20.22.4.88}
                    index: 29
                  extension: {index: 30}
                required: [root]
                extensions: {}
              typeCode: {index: 31}
              time: {index: 32}
              assignedEntity:
                constraint:
                  4537-8967: {human: '**SHOULD** include assignedEntity/assignedPerson/name AND/OR assignedEntity/representedOrganization/name (CONF:4537-8967).', source: 'http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity', severity: warning, expression: assignedPerson.name.exists() or representedOrganization.name.exists()}
                  should-addr: {human: SHOULD contain addr, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity', severity: warning, expression: addr.exists()}
                  should-telecom: {human: SHOULD contain telecom, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity', severity: warning, expression: telecom.exists()}
                index: 33
                elements:
                  code:
                    index: 34
                    elements:
                      code:
                        pattern: {type: Code, value: GUAR}
                        index: 35
                      codeSystem:
                        pattern: {type: String, value: 2.16.840.1.113883.5.110}
                        index: 36
                    required: [codeSystem, code]
                  addr: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/AD', index: 37}
                  telecom: {index: 38}
                required: [code]
            required: [typeCode, templateId]
  text:
    short: SHOULD reference the portion of section narrative text corresponding to this entry
    index: 8
    elements:
      reference:
        constraint:
          value-starts-octothorpe: {human: 'If reference/@value is present, it SHALL begin with a ''#'' and SHALL point to its corresponding narrative', source: 'http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity', severity: error, expression: value.exists() implies value.startsWith('#')}
        index: 9
package_version: 4.0.0-ballot
class: logical
kind: logical
url: http://hl7.org/cda/us/ccda/StructureDefinition/PolicyActivity
base: http://hl7.org/cda/stds/core/StructureDefinition/Act
version: 4.0.0-ballot
required: [id, participant, statusCode, templateId, performer]