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RFC Proposal

  • RFC Proposal ID: 0000-coverage-fhir-r4-carin
  • Start Date: TBD
  • RFC PR: TBD
  • JIRA Ticket(s):
  • BFD-265

This RFC proposes that our team migrate from BFD v1 STU3 Coverage FHIR resource to the FHIR release, R4 and implement CARIN Coverage profile.

Status

  • Status: Implemented
  • Implementation JIRA Ticket(s):

Table of Contents

Motivation

This change will make BFD's Coverage resource increase the system's conformance with FHIR R4 and industry alliance ecosystems like CARIN. This will also make integration and interoperability with all our peer partners seamless by enabling to provide FHIR-R4 validated and conformant Coverage resources (Beneficaries Coverage and Eligibility data).

Proposed Solution

BFD proposes to provide a new v2 endpoint to support Coverage FHRI-R4 and CARIN conformant resource.

https://localhost:1337/v2/fhir/Coverage?beneficiary=-19990000000001&_format=json

Coverage FHIR R4 (US-Core, Normative release): http://hl7.org/fhir/R4/Coverage.html

CARIN Coverage Profile: http://build.fhir.org/ig/HL7/carin-bb/StructureDefinition-CARIN-BB-Coverage.html

Detailed Design

HAPI Version to be used: HAPI FHIR 4.1.0

HAPI 4.1.0 Coverage Data Model class to be used: org.hl7.fhir.r4.model.Coverage

POC Code snippet: 

  // Slicing implementation for Coverage Class
  coverageSlcing = new Coverage();

  coverageSlcing.addClass_().setValue("Medicare").getType().addCoding().setCode("subgroup")
      .setSystem("http://terminology.hl7.org/CodeSystem/coverage-class").setDisplay("SubGroup");
  coverageSlcing.addClass_().setValue("Part C").getType().addCoding().setCode("subplan")
      .setSystem("http://terminology.hl7.org/CodeSystem/coverage-class").setDisplay("SubPlan");

Below are the payload changes being proposed in Coverage resource:

Changes:

Slicing:

Current State: No Slicing.

Future State: The element Coverage.class is sliced based on the values of value:type.

Slicing Implementation: POC code above.

Slicing codes are used from the below list:

http://terminology.hl7.org/CodeSystem/coverage-class version 4.0.1

Code   Definition
subgroup:     A sub-group of an employee group
subplan:     Coverage Medicaid number

Slicing Rules: https://www.hl7.org/fhir/valueset-resource-slicing-rules.html

Extensions/Code System Changes:

Coverage.status
• Change value set From:
http://hl7.org/fhir/ValueSet/fm-status
To:
http://hl7.org/fhir/ValueSet/fm-status|4.0.1

Coverage.relationship
• http://terminology.hl7.org/CodeSystem/subscriber-relationship

Coverage.type
• http://hl7.org/fhir/valueset-coverage-type.html

Coverage.class.type
• http://terminology.hl7.org/CodeSystem/coverage-class

Coverage.status field

Type boolean

MANDATORY New Fields to be Added:

Coverage.class.type

Type of class such as 'group' or 'plan' (CodeableConcept). E.g. Medicare.

Coverage.class.value

Value associated with the type (String). E.g “Part D”.

Additional CARIN MANDATORY New Fields to be Added:

Subscriber Id:

ID assigned to the subscriber.

Relationship:

Beneficiary relationship to the subscriber. The relationship between the Subscriber and the Beneficiary. http://hl7.org/fhir/ValueSet/subscriber-relationship

Cardinality Rule Changes (From STU3 to R4)

Coverage.status

Min Cardinality changed from 0 to 1

Coverage.beneficiary

Min Cardinality changed from 0 to 1

Coverage.payor

Min Cardinality changed from 0 to 1.

Coverage.class

Max Cardinality changed from 1 to *

Renamed Items:

Coverage.class (Renamed from grouping to class)

Deleted Elements:

Coverage.grouping

R4 Code Systems Changes:

Coverage.status
• Change value set from:
http://hl7.org/fhir/ValueSet/fm-status
To:
http://hl7.org/fhir/ValueSet/fm-status|4.0.1

Coverage.relationship
• http://terminology.hl7.org/CodeSystem/subscriber-relationship

Coverage.type
• http://hl7.org/fhir/valueset-coverage-type.html

Coverage.class.type
• http://terminology.hl7.org/CodeSystem/coverage-class

R4 Non-Conformance Errors:

FHIR-R4 Coverage Resource Validation errors:

Next issue ERROR - null - cvc-complex-type.2.4.b: The content of element 'Coverage' is not complete. One of '{"http://hl7.org/fhir":id, "http://hl7.org/fhir":meta,
"http://hl7.org/fhir":implicitRules,
"http://hl7.org/fhir":language,
"http://hl7.org/fhir":text,
"http://hl7.org/fhir":contained,
"http://hl7.org/fhir":extension,
"http://hl7.org/fhir":modifierExtension,
"http://hl7.org/fhir":identifier,
"http://hl7.org/fhir":status}' is expected.

CARIN Validation errors:

Next issue ERROR - Coverage - Unable to locate profile http://hl7.org/fhir/us/carin/StructureDefinition/carin-bb-coverage Next issue ERROR - Coverage - Unable to locate profile http://hl7.org/fhir/us/carin/StructureDefinition/carin-bb-Coverage Next issue INFORMATION - Coverage.extension[0] - Unknown extension

http://hl7.org/fhir/us/core/StructureDefinition/us-core-race

Next issue INFORMATION - Coverage.extension[1] - Unknown extension http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity

Next issue INFORMATION - Coverage.extension[2] - Unknown extension http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex

CARIN IG:

https://build.fhir.org/ig/HL7/carin-bb/StructureDefinition-CARIN-BB-Coverage.html

Summary
Mandatory: 2 elements
Must-Support: 1 element

Slices
This structure defines the following Slices:
The element Coverage.identifier is sliced based on the values of value:type, value:system

Current State

BFD v1: Current State Coverage Resource

Future State

BFD v2: Future State Coverage Resource

Differential View

Differential_view_1

Differential_view_2

Differential_view_3

Unresolved Questions

The following questions need to be resolved prior to merging this RFC:

  1. Can raw un-hashed MBI be used a Subscriber Id? YES

RESOLVED

  1. What code for Coverage “type” can be used from this Code System:

http://terminology.hl7.org/CodeSystem/v3-ActCode

A code from above code system below and if this can be used? YES

SUBSIDIZ: subsidized health program

Definition: A government health program that provides coverage for health services to persons meeting eligibility criteria such as income, location of residence, access to other coverages, health condition, and age, the cost of which is to some extent subsidized by public funds.

RESOLVED

Proposed Solution: Drawbacks

Supporting both v1 and v2 in parallel may cause slight performance issues.

Proposed Solution: Notable Alternatives

NA.

Prior Art

BFD project already has a reasonable amount of experience with FHIR DSTU3/R3, those experiences have been very positive.

Future Possibilities

No future possibilities are being seriously considered at this time.

Addendums

The following addendums are required reading before voting on this proposal: None